Crohn’s Disease: How Sure is Sure?

Abstract

Introduction: Endoscopy with biopsy has been the gold standard for diagnosis of Crohn’s disease. A 33-year-old male presented with mid epigastric discomfort and constipation. Miralax and protonix was initiated. Over the ensuing 6 weeks, his symptoms of abdominal pain and bloating worsened. He lost 15 pounds, and had night sweats, early satiety, and abdominal tenderness. A CT scan of the abdomen showed abnormally thickened proximal ileal loops consistent with Crohn’s disease, and prednisone was started. He returned within days with worsening abdominal pain. Urgent colonoscopy with ileal visualization showed no significant abnormalities. Steroids were continued. CT enterography showed a segment of small bowel within the mid abdomen extending right to left with diffuse wall thickening as well as cystic implants within the omentum and adenopathy at the mesenteric root. Eventually, he experienced worse abdominal pain, fever, and vomiting. CT showed intra-peritoneal air consistent with a perforated hollow viscous. Emergent laparotomy with biopsy of peritoneal implants confirmed the diagnosis of intermediate grade follicular center cell lymphoma. Bowel perforation in GI lymphomas is seen in approximately 9% of intestinal lymphoma cases, half of which occur after initiation of chemotherapy. Clinical entities that mimic intestinal lymphoma include Crohn’s disease, carcinomatosis, carcinoid tumors, and ischemic injury. Bowel perforation in GI lymphomas is seen in approximately 9% of intestinal lymphoma cases, half of which occur after initiation of chemotherapy. Clinical entities that mimic intestinal lymphoma include Crohn’s disease, carcinomatosis, carcinoid tumors, and ischemic injury. Clues in this case that Crohn’s disease was not the right diagnosis was the rapid progression of disease, night sweats, weight loss, and absence of diarrhea. CT enterography showed progression of disease uncharacteristic of Crohn’s disease. Radiographs often depict abnormalities in patients with inflammatory bowel disease (IBD). However, a false positive rate of 16-20% with the low positive predictive value of a normal radiograph (62%) make radiography a poor diagnostic test. The empiric use of steroids in this patient may have not only increased the risk of bowel perforation, but was likely the cause for inconclusive histopathology on colonoscopic biopsy. This serves to reinforce that it is still crucial to have a biopsy-proven diagnosis of Crohn’s disease prior to initiation of steroids.Figure 1