S2792 A Tale of Three Stomas: A Challenging Case of Inflammatory Bowel Disease

Abstract

Introduction: Inflammatory bowel disease (IBD) and diverticular disease have many overlapping sequelae. It can be difficult to distinguish between them in an acute presentation. Here, we report a challenging case of IBD that originally presented as complicated diverticular disease. We highlight the diagnostic and management considerations. Case Description/Methods: A 75-year-old female without personal or family history of IBD presented in June 2021 with abdominal pain and fever, was diagnosed with uncomplicated diverticulitis and treated with a course of antibiotics. She recovered clinically but presented in July 2021 with worsening abdominal pain and bloody diarrhea. She was found on imaging to have a colonic perforation and abscess. She was taken for a Hartmann procedure with sigmoidectomy and colostomy formation, with surgical pathology suggestive of acute diverticulitis. Abdominal pain and bloody ostomy output continued. She presented to our medical center in September 2021. Evaluation showed deep ulcerations and spontaneous friability, concerning for IBD. She was started on steroids but she proved refractory. We then offered rescue infliximab, after which she clinically improved. She was maintained on infliximab as an outpatient. Before repeat endoscopic evaluation, she presented again to the hospital with abdominal pain and was found to have another colonic perforation. She underwent a completion subtotal colectomy, extensive lysis of adhesions and received an end ileostomy. Pathology showed severely active chronic pancolitis with ulceration. She currently is in clinical remission, not currently on any IBD therapy. Discussion: The diagnosis for this patient has proved difficult, given her initial acute presentation. Complicated diverticulitis has overlapping features with IBD, and is more prevalent than IBD. It is less prevalent in the IBD population, with one study showing prevalence in ulcerative colitis (UC) of 10.8% compared to 27.8% in healthy controls. Endoscopic evaluation was important in understanding the presence of IBD, though it has been challenging to define a distinct entity of UC versus Crohn’s disease given her history of abscess and colonic perforation. The rate of intra-abdominal abscess in UC is low but has been described. In one single center analysis, the rate of intra-abdominal abscess in UC vs Crohn’s disease with 0.8% vs 2.4%, respectively. After surgical recovery, we plan for small bowel evaluation to further delineate the extent of inflammation.Figure 1.: Image from colonoscopy from 9/21/21 showing erythema, ulceration, friability.