S2720 Crohn’s Disease Manifesting as a Jejunal Obstruction at Diagnosis

Abstract

Introduction: Crohn’s disease is an inflammatory bowel disease caused by transmural inflammation and may affect any portion of the luminal gastrointestinal tract. It is commonly associated with abdominal pain, fatigue, weight loss and diarrhea as the initial presentation. It is vastly uncommon that Crohn’s disease is diagnosed as a bowel obstruction as it initial presentation. We present a gentleman whose initial presentation of Crohn’s disease was a small bowel obstruction from an inflammatory mass. Case Description/Methods: Patient is a 21-year-old male with no significant past medical history who presented to the ED with myalgias, abdominal pain, nausea, and vomiting for one month. He was recently seen at a different hospital for similar symptoms. He underwent EGD which showed Mallory Weiss tears in the esophagus and a gastric emptying study which showed abnormal transit of solids and liquids. He was treated at that time for gastroparesis. On this admission, he had a normal gastric emptying study. He continued to have large amounts of emesis in amounts over one liter in volume. A CT abdomen and pelvis with oral contrast showed marked distention and dilation of the duodenum to the level of the superior mesenteric artery to where there was relative obstruction and moderate narrowing and a stricture in the proximal to mid jejunum with mesenteric nodal prominence. A small bowel series with gastrograffin had similar findings. Patient underwent a laparoscopic small bowel resection where a small bowel mass at the level of the mid jejunum was found, causing focal narrowing and partial obstruction. The mass pathology revealed a central structure with mural thickening and features suggestive of Crohn’s disease. His post operative course was unremarkable, and he followed up with gastroenterology outpatient for evaluation and treatment of his new diagnosis of Crohn’s disease. (Figure) Discussion: Crohn’s disease includes a wide collection of clinical presentations. Small bowel obstruction progresses in moderate to severe cases of Crohn’s, which typically is a chronic issue. To our knowledge, one other case report has been published with the initial presentation of Crohn’s disease manifesting as an obstruction. Our patient had misleading initial work up and isolated jejunal involvement without other intestinal involvement which may have contributed to the delay in his diagnosis.Figure 1.: Left and middle panels reveal the small bowel series with small intestine narrowing and dilatation. Right similarly reveals small bowel dilation and mesenteric nodal prominence.