Time for Remicade? An Unusual Cause of Recurrent Abdominal Pain

Abstract

Purpose: A 54-year-old male presented to the outpatient clinic with 2 weeks of anorexia, malaise, and constant, sharp left lower abdominal pain. CT of abdomen and pelvis showed a small area of fat stranding in anterior midline of lower abdomen and adjacent small bowel wall thickening. He received empiric antibiotics with resolution of his pain at one week follow-up. He represented to the emergency room after 2 weeks with recurrent lower abdominal pain, nausea, vomiting, and non-bloody diarrhea. Repeat CT revealed a 5 cm fluid collection in the mid abdomen adjacent to the ileum and oral contrast seen within the extraluminal collection. Upper endoscopy revealed a small linear ulcer in the duodenum; colonoscopy showed a diminutive cecal polyp and normal terminal ileum. Histology of the ileum was normal. Antibiotics were administered. CT 3 days later showed improvement in extraluminal fluid collection. Two weeks later he complained of recurrent left sided abdominal pain. CT enterography was then done showing fat stranding at the previously affected loop of small bowel but no discrete extraluminal abscess or fluid collection. Recurrent nausea, left lower quadrant pain, subjective fevers and diarrhea without blood developed and he was admitted to the inpatient GI service. Physical exam revealed the patient to be afebrile with normal hemodynamic parameters. Oral examination revealed upper dentures. Abdomen was flat, with normal bowel sounds, but was markedly tender to palpation in his left lower quadrant with voluntary guarding. Rectal examination was normal. Labs now showed WBC 8.2, Hgb 9, MCV 84.5, platelets 418, albumin 3.1, Sed rate 58, Saccharomyces IgG was 34.7. Given the severity and focality of the patient's abdominal pain general surgery was consulted and performed a diagnostic laparoscopy. Approximately 30 cm from the ileocecal valve a segment of small bowel was noted to be matted and adherent to the sigmoid colon. A foreign body could be palpated in the lumen of the small bowel and a blue wooden toothpick was seen protruding through the ileal lumen. 15cm of distal ileum was resected and a side to side small bowel anastomosis was performed. The patient made an uneventful postoperative recovery and was discharged 9 days later.Figure: [904]