Ileal DALM in Crohnʼs Disease: An Overlooked Entity?

Abstract

Background: Patients with inflammatory bowel disease (IBD) are at an increased risk for developing neoplasia. Dysplasia associated lesions or masses (DALMs) are traditionally described in the colon and may represent underlying malignancy. Current surveillance protocols for malignancy generally require colonic biopsies. Small bowel malignancy among patients with Crohn's Disease (CD) has been described, but surveillance protocols for these patients have not been well defined. Case Report: We report here a 62 year old male with a history of umbilical hernia repair who presented with abdominal pain, nausea, and vomiting. He was previously diagnosed with mixed-pattern irritable bowel syndrome and had two episodes of small bowel obstructions (SBO) that were attributed to adhesions and managed conservatively. He had a heavy smoking and NSAID use history. The patient had never had a colonoscopy before and denied a family history of IBD or GI malignancy. Physical exam was significant for a distended abdomen. CRP was elevated at 3.82 mg/dL (normal < 0.5 mg/dL) and ESR was normal. A CT scan showed partial SBO with a long segment of ileal wall thickening. Colonoscopy showed fistulae at 45 and 55 cm from the anal verge. Abnormal polypoid lesions were seen in the terminal ileum (Fig 1) and biopsies showed tubulovillous-like lesion with low grade dysplasia, located within the distal portion of inflamed ileum compatible with DALM (Fig 3). A definitive diagnosis of CD could not be made and hence no medical therapy was started. CT enterography showed inflammation involving 20 cm of the distal ileum. A retrograde double balloon enteroscopy was performed, but the ileum could not be reached.Figure 1Figure 3As malignancy could not be ruled out, the decision was made for exploratory laparotomy that showed creeping fat and severe distal ileitis with enter-entero and entero-sigmoid fistulas. The patient underwent ileosigmoid fisula closure, and ileocolic resection with primary ileo-ascending colon anastomosis. Gross pathology confirmed severe Crohn's ileitis with tubulovillous-like lesions in TI with low grade dysplasia compatible with DALM in the distal ileum (Fig 2,3). No colitis was appreciated.Figure 2Conclusion: This case report demonstrates a DALM that affected the distal ileum in the setting of severe untreated ileal Crohn's. This brings into question the role for endoscopic surveillance and possible need for obtaining tissue to evaluate for malignancy among patients with CD with small bowel involvement.