Ileocecal Involvement Research Articles

Ileocecal involvement in intestinal Behçet's disease and Crohn's disease: comparison of clinicopathological and immunophenotypic features.

Intestinal Behçet's disease (BD) predominantly affects the ileocecal region and is currently diagnosed based on endoscopic features and clinical manifestations. It is difficult to distinguish between intestinal BD and Crohn's disease (CD) due to similar patient populations, gastrointestinal involvement, extraintestinal manifestations, and long-term recurrent course. In this study we aimed to compare the clinicopathological and immunophenotypic features of intestinal BD to CD. The medical and pathological records of 29 cases of intestinal BD and 120 cases of CD diagnosed at Sir Run Run Shaw Hospital were retrospectively analyzed. Immunohistochemistry for CD3, CD20, FOXP3, myeloperoxidase, and quantitative analysis of the infiltrating inflammatory cells was conducted. Intestinal BD with ileocecal ulcer had a higher incidence of abdominal pain and a higher erythrocyte sedimentation rate than CD, while chronic diarrhea was more common in CD. Excessive neutrophils in the mucosal lamina propria, neutrophilic exudate on the ulcer surface, and prominent lymphocytic infiltration in ulcer tissues were statistically more frequent in intestinal BD than in CD. The numbers of FOXP3+ T cells, CD3+ T cells, and CD20+ B cells in biopsy tissue from intestinal BD were significantly higher than CD, but the ratio of FOXP3+ T cells to CD3+ T cells was not statistically different. Besides the typical clinical and endoscopic findings, diagnostic biopsies from the ileocecal region in intestinal BD show some histological and immunophenotypic features that are different from CD, which may be useful in distinguishing these two entities.

S2214 A Rare Case of Secondary Extramedullary Plasmacytoma With Ileocecal Involvement

Introduction: Extramedullary plasmacytomas (EMPs) are a rare type of plasma cell dyscrasia characterized by the neoplastic proliferation of plasma cells in soft tissue.EMPs share characteristics with multiple myeloma (MM) and can present as primary tumors or secondary to other plasma cell neoplasms.Herein we present an extremely rare case of a patient with established MM who was found to have an asymptomatic ileocecal mass with biopsy findings consistent with secondary EMP. Case Description/Methods: A 62-year-old female with a past medical history of MM and Ulcerative Colitis (UC) presented to the gastroenterology clinic for evaluation of her UC before consideration of an experimental therapy trial for her refractory MM.On presentation, she denied changes in her bowel habits or blood in her stool. Lab results 2 weeks prior to presentation were significant for leukopenia at 2.9k/uL, normocytic anemia with hemoglobin at 8.5gm/dL, Calcium 8.2 mg/dl, and total protein of 5.7g/dl. Colonoscopy showed nodular, ulcerated mucosa at the hepatic flexure as well as a large polypoid non-bleeding, non-obstructing, non-circumferential mass at the ileocecal valve. Histopathology of the mass returned positive for CD138 Kappa and negative for lambda AE1/AE3, CAM 5.2, GATA3, ER, consistent with a diagnosis of plasma cell myeloma. The patient continued on salvage chemotherapy but passed shortly thereafter (Figure). Discussion: Plasma cell neoplasms (PCNs) involving extra-osseous tissues are known as extramedullary plasmacytomas (EMPs).EMPs are further classified into primary EMPs, which are localized proliferation of clonal plasma cells in the absence of a systemic plasma cell dyscrasia, and secondary EMPs, where there is already a known primary PCN present. To the best of our knowledge, secondary EMP involving the small intestine and cecum is rare and only reported in a handful of case reports.Due to the indolent course of EMPs, nonspecific gastrointestinal manifestations may go undiagnosed in a subset of patients with MM. The prognosis of secondary EMP involving the gastrointestinal tract remains unclear, however, the limited data we have indicates a poor prognosis.On the other hand, novel treatments of MM continue to improve survival rates in patients with MM. As mortality in these patients decreases, the incidence of secondary EMPs is expected to proportionately rise as well. As such, more data is needed to understand how to monitor and treat this patient population for extramedullary involvement in order to generate good outcomes.Figure 1.: Large polypoid non-bleeding, non-obstructing, non-circumferential mass at the ileocecal valve before and after biopsy.

Development and validation of prognostic scoring in primary intestinal diffuse large B-cell lymphoma: a single-institution study of 184 patients.

BackgroundThe incidence of primary intestinal diffuse large B-cell lymphoma (PI-DLBCL) is much lower than primary gastric DLBCL, and large-scale analyses on the clinical characteristics, molecular features, therapeutic strategies, and risk stratification have been seldomly performed in PI-DLBCL.MethodsTo assess prognostic model development, 107 PI-DLBCL patients diagnosed before 2014 were studied for prognosis factors including different primary involved sites and treatment strategies. For internal validation, a non-random split sample set with 77 PI-DLBCL patients after 2014 was included for validation of the prognosis factors.ResultsPatients with an ileocecal lesion presented with better survival time than those with non-ileocecal sites, with surgical resection significantly influencing the prognosis. Non-ileocecal patients who underwent surgery with lymphadenectomy had superior overall survival (OS) and progression-free survival (PFS) compared to those receiving surgery without lymphadenectomy or those not receiving (without) surgery. For ileocecal patients, surgery with or without lymphadenectomy resulted in better OS and PFS than those without surgery. For biomarker analysis, only BCL-2 >50% or Ki67 >80% on tumor cells indicated poor clinical outcome. In multivariate analysis, age, Eastern Cooperative Oncology Group (ECOG) score, and site of origin were independent prognostic factors for inferior OS in PI-DLBCL. A prognosis model was set up based on age, ECOG score, and site of origin, and validated well.ConclusionsThe prognosis in patients with PI-DLBCL with ileocecal involvement showed was better than those with non-ileocecal involvement. Surgical strategy can impact the clinical outcome of PI-DLBCL patients.

Calidad de vida en pacientes con enfermedad de Crohn ileocecal posterior a tratamiento quirúrgico

Introduction: Ileocecal involvement in Crohn's disease is the most frequent presentation. There is little evidence of the impact of surgical treatment on the quality of life of patients. Materials and methods:A study retrospective study of a prospectively collected database was carried out including all patients who underwent surgery for Crohn's disease with ileocecal involvement by a single group of surgeons during a period of 30 months. Our primary outcome was the comparison of quality of life before and 4 months after surgical intervention by means of two validated questionnaires (Short Form-36, Inflammatory Bowel Disease Questionnaire). We additionally assessed the morbidity of the procedures. Results:Nineteen patients who underwent surgery were included in the study. Median age was 34 years (23-72), 16 patients underwent laparoscopic surgery and 2 patients required re operations. Median follow-up was 16 months (4-30). Three patients (16%) presented major complications. Patients showed an average improvement of 46% in the parameters assessed by the SF-36 questionnaire (p<0.0001) and 81 points (p<0.0001) in the values ​​of the IBDQ questionnaire after surgery. Conclusion:The surgical treatment of Crohn's disease with ileocecal involvement presents good post-operative results and a significant improvement in the quality of life of patients after the procedure.

Rodeando al enemigo: Colectomía derecha laparoscópica por enfermedad de Crohn estenosante y fistulizante.

Nicolás Avellaneda (1) (ORCID 0000-0002-6802-7125), Augusto Carrie (1) (ORCID 0000-0003-4226-7240), Federico Veracierto (1) (ORCID 0000-0003-3363-8935).&#x0D; &#x0D; Centro de Educación Médica e Investigaciones Clínicas “Norberto Quirno” (CEMIC). Galván 4102, C1431 CABA, Argentina.&#x0D; &#x0D; &#x0D; &#x0D; Introducción.&#x0D; &#x0D; &#x0D; La enfermedad de Crohn presenta una incidencia aumenta en los últimos años en los países industrializados, y la afectación ileocecal es la mas frecuente en esta patología.&#x0D; En una primera instancia los pacientes puede recibir tratamiento médico, pero un porcentaje significativo de estos pueden evolucionar hacia complicaciones de la enfermedad como estenosis o fístulas. Cuando estas se presentan, deben ser tratadas quirúrgicamente, representando un desafío para el equipo quirúrgico porque se trata de pacientes en mal estado general y con gran compromiso inflamatorio a nivel abdominal que dificulta la correcta identificación de los planos anatómicos.&#x0D; &#x0D; 2) Descripción.&#x0D; Se presenta el caso de un paciente de 84 años que ingresa por guardia en nuestra institución por presentar diagnóstico de enfermedad de Crohn de 10 años de evolución, mal estado general y deterioro nutricional severo. Al examen físico se palpa tumor a nivel de flanco derecho y fosa ilíaca derecha.&#x0D; Entero-RMN: Ileon terminal con fístula hacia colon derecho y transverso y cavidad intermedia con colección de 3 cm.&#x0D; Laboratorio: Glóbulos blancos: 12.000x10-9/L, Albúmina: 1,3 gr/dl.&#x0D; Se decide internar al paciente, se instaura tratamiento antibiótico, medidas de sostén y nutrición parenteral total.&#x0D; A las 3 semanas, el paciente presenta mejora en los parámetros nutricionales y en el estado general, por lo cual se programa tratamiento quirúrgico de la patología.&#x0D; Se realiza una laparoscopía exploradora donde se evidencia gran tumor inflamatorio que involucra ileon terminal, colon derecho y transverso. Se logra logra la movilización completa de las estructuras mencionadas, las cuales se exteriorizan por una mini laparotomía mediana supraumbilical, y se hace la resección en bloc del tumor inflamatorio, confeccionando una ileostomía terminal y abocando el colon transverso en tejido celular subcutáneo.&#x0D; Paciente presenta buena evolución postoperatoria, recibiendo el alta senatorial al séptimo día postoperatorio sin complicaciones.&#x0D; &#x0D; 3) Conclusiones.&#x0D; &#x0D; El tratamiento quirúrgico de la enfermedad de Crohn representa un desafío para el cirujano. Realizado por vía laparoscópica y luego de optimizar al paciente desde el punto de vista clínico y nutricional, se pueden obtener buenos resultados postoperatorios.

Rodeando al enemigo: colectomía derecha laparoscópica por enfermedad de Crohn estenosante y fistulizante

1) Introduction. Crohn's disease has an increasing incidence in recent years in industrialized countries, and ileocecal involvement is the most frequent in this pathology. Firstly, patients can receive medical treatment, but many of them can present complications of the disease such as stenosis or fistulas. When these appear, they must be treated surgically, representing a challenge for the surgical team because this are patients in poor general condition and with a large abdominal inflammatory compromise that makes it difficult to correctly identify the anatomical planes. 2) Description. We present the case of an 84-year-old patient who is admitted to our institution in Emergency Service for presenting a diagnosis of Crohn's disease of 10 years of evolution, poor general condition and severe nutritional deterioration. Physical examination revealed a palpable tumor at the level of the right flank and right iliac fossa. Entero-MRI: Terminal ileum with fistula towards the right and transverse colon and intermediate cavity with a 3 cm collection. Laboratory: White blood cells: 12,000x10-9 / L, Albumin: 1.3 gr / dl. Decission is made to admit the patient, antibiotic treatment, support measures and total parenteral nutrition were instituted. At 3 weeks, the patient shows improvement in nutritional parameters and general condition, for which surgical treatment of the pathology is scheduled. An exploratory laparoscopy is performed where a large inflammatory tumor involving the terminal ileum, right and transverse colon is evidenced. Complete mobilization of the aforementioned structures is achieved, which are externalized by a supraumbilical median mini laparotomy, and enbloc resection of the inflammatory tumor is made, performing a terminal ileostomy and leaving the transverse colon in subcutaneous cellular tissue. Patient presented good postoperative evolution, receiving sanatorial discharge on the seventh postoperative day without complications. 3) Conclusions. Surgical treatment of Crohn's disease represents a challenge for the surgeon. Performed laparoscopically and after optimizing the patient from a clinical and nutritional point of view, good postoperative results can be obtained.

S2821 Ileocolonic Intussusception Associated Large B-Cell Lymphoma

INTRODUCTION: Intussusception is characterized by the telescoping of a more proximal portion of the gastrointestinal tract into a more distal portion. This is rare in the adult population, representing 5% of all cases of intussusception. Unlike in children, a pathological lead point is detected in 70–90% of cases, with up to 65% being malignant. Common malignancies leading to intussusception in the small intestine include primary adenocarcinoma, gastrointestinal stromal tumors, carcinoid tumors, and lymphoma. CASE DESCRIPTION/METHODS: A 35-year-old male presented with one month of intermittent right-sided abdominal pain. He reported normal bowel movements and denied nausea or vomiting. On presentation his vitals were unremarkable. Physical examination revealed mild abdominal distention with RLQ tenderness. CT abdomen/pelvis demonstrated RLQ ileocolonic intussusception without obstruction. Initial laboratory values were within normal limits. Colonoscopy revealed a dilated cecum and distal ileum with ileocolonic intussusception, with gross examination concerning for malignancy. Terminal ileal biopsy revealed benign small bowel mucosa with active inflammation. Alpha-fetoprotein was 8.5 ng/mL and carcinoembryonic antigen 0.5 ng/mL .CT chest showed no signs of metastasis. The patient underwent laparoscopic right hemicolectomy with extended small bowel resection. Surgical pathology revealed large B-cell lymphoma of the terminal ileum (positive for CD20, Ki-67) and twenty reactive lymph nodes. Postoperative course was uncomplicated and the patient was discharged home with Hematology/Oncology follow up. DISCUSSION: Intussusception is uncommon in adults, with the ileocolic or ileocecal variety comprising the most rare category. In a review of 14 papers in which 396 intussusception cases were presented, only 83 (20.9%) had ileocolic or ileocecal involvement. Of these, intussusception secondary to malignant causes occurred in 144 (36.4%) cases, with 23 of them resulting from lymphoma. Presentation usually includes non-specific symptoms such as colicky abdominal pain (85%–100%), nausea (41%–75%), vomiting (35%–70%), bleeding (16.4%–27.3%) diarrhea and constipation (22.5%–69%), which play a role in its challenging diagnosis. Considering adult intussusception in patients with recurrent abdominal pain is of critical importance given its high association with malignancy. This case highlights the uncommon diagnosis of adult intussusception caused by large B-cell lymphoma.Figure 1.: CT scan showing RLQ ileocolonic intussusception without obstruction.Figure 2.: Colonoscopy revealed ileocolonic intussusception.

Endometriosis of the Appendix: When to Predict and How to Manage—A Multivariate Analysis of 1935 Endometriosis Cases

To evaluate appendiceal endometriosis (AE) prevalence and risk factors in endometriotic patients submitted to surgery. A retrospective cohort study. A tertiary level referral center, university hospital. One thousand nine hundred thirty-five consecutive patients who underwent surgical removal for symptomatic endometriosis. Electronic medical records of patients submitted to surgery over a 12-year period were reviewed. We assessed any correlation between demographic, clinical, and surgical variables and AE. In our center, appendectomy was performed using a selective approach. Appendix removal was performed in case of gross abnormalities of the organ, such as enlargement, dilation, tortuosity, or discoloration of the organ or the presence of suspected endometriotic implants. AE prevalence was 2.6% (50/1935), with only 1 false-positive case at gross intraoperative evaluation. In multivariate analysis using a stepwise logistic regression model, independent risk factors for AE were adenomyosis (adjusted odds ratio [aOR] = 2.48; 95% confidence interval [CI], 1.32-4.68), right endometrioma (aOR = 8.03; 95% CI, 4.08-15.80), right endometrioma ≥5 cm (aOR = 13.90; 95% CI, 6.63-29.15), bladder endometriosis (aOR = 2.05; 95% CI, 1.05-3.99), deep posterior pelvic endometriosis (aOR = 5.79; 95% CI, 2.82-11.90), left deep lateral pelvic endometriosis (aOR = 2.11; 95% CI, 1.10-4.02), and ileocecal involvement (aOR = 12.51; 95% CI, 2.07-75.75). Among patients with endometriosis submitted to surgery, AE was observed in 2.6%, and it was associated with adenomyosis, large right endometrioma, bladder endometriosis, deep posterior pelvic endometriosis, left deep lateral pelvic endometriosis, and ileocecal involvement.

A Perf-ect Diagnosis: Ileocolonic Crohn Disease Presenting as Acute Appendicitis

Background: Crohn disease (CD) involving the appendix is rare, but often presents as lower abdominal pain. Occasionally patients may present with symptoms mimicking acute appendicitis. A retrospective review from 2014 cited an overall incidence of CD at the time of appendectomy for acute appendicitis to be only 0.55% Case: An 18-year-old male without known past medical history presented with intermittent right lower quadrant abdominal pain for 3 weeks. CT scan revealed acute appendicitis with possible early perforation and he was treated non-operatively with antibiotics. A repeat CT scan 16 days later demonstrated bowel wall thickening of the distal ileum, proximal right colon, and appendix. At the surgical follow up visit he admitted to a long-standing history of 5-6 loose bowel movements per day and he was referred to gastroenterology. He soon returned to the hospital with recurrent abdominal pain and fever. CT scan demonstrated persistent inflammation in these areas. Colonoscopy revealed an edematous ileocecal valve and a narrowed, inflamed cecal lumen with ulcerations. Biopsies demonstrated features suggestive of CD, but no granulomas. Fecal calprotectin was elevated to 212 mcg/g. He was discharged with a steroid taper, but returned to the office with a complaint of right groin pain and on exam had a positive psoas sign. MRE demonstrated a right psoas abscess and continued inflammation in the terminal ileum and cecum and he was re-admitted for percutaneous drainage and IV antibiotics. Two weeks later he underwent open ileocecectomy and pathology confirmed the diagnosis of CD. Discussion:The overall incidence of CD involving the appendix is low, with a 2001 study citing appendiceal involvement in only 0.2% of patients with CD. Isolated appendiceal CD is even rarer with only 229 cases reported in the literature, and prognosis appears to be better with post-appendectomy recurrence rates of only 0-10%. Conversely, appendectomy in patients with CD with ileocecal involvement has a high rate of fistula formation. There has been recent inconsistent literature regarding a proposed increased risk of developing CD following appendectomy, but this is felt to be largely due to diagnostic bias. Overall, this case highlights the importance of keeping an initial broad differential, taking an adequate history, and having a high index of suspicion when working up a case of suspected appendicitis, especially with atypical symptoms or a prolonged course.

Surgical care of the pediatric Crohn’s disease patient

Despite the significant advances in the medical management of inflammatory bowel disease over the last decade, surgery continues to play a major role in the management of pediatric Crohn’s disease (CD). While adult and pediatric Crohn’s disease may share many clinical characteristics, pediatric Crohn’s patients often have a more aggressive phenotype, and the operative care given by the pediatric surgeon to the newly diagnosed Crohn’s patient is very different in nature to the surgical needs of adult patients after decades of disease progression. Children also have the unique surgical indication of growth failure to consider in the overall clinical decision making. While surgery is never curative in CD, it has the ability to transform the disease process in children, and appropriately timed operations may have tremendous impact on a child’s physical and mental maturation. This monograph aims to address the surgical care of Crohn’s disease in general, with a specific emphasis on the surgical treatment of small intestinal and ileocecal involvement.

IgG4-related lung disease:a clinical analysis and literature review

To summarize the clinical features, diagnosis and treatment experience of IgG4-related lung disease for the sake of improving clinical understanding of this disease and reducing the misdiagnosis and mistreatment rates. To analyze the general situation, clinical manifestation, laboratory examination, histopathology, therapy and prognosis of 2 patients with IgG4-related lung disease, who were admitted in the department of respiratory diseases at Changhai Hospital. Publications related to IgG4 lung disease were reviewed. Both patients were male with elevated serum IgG4 level (2.25 g/L and 10 g/L respectively). In one patient, radiologic finding showed solid nodules in the lung with ileocecal involvement. He responded well to glucocorticoid. The other patient's computed tomography of lung demonstrated bronchovascular type. Glucocorticoid therapy was effective to both patients. A total of 69 cases with IgG4-related lung disease were reported worldwide, among whom 39 cases were admitted with chief complaints of respiratory symptoms. However, there were 41 cases suffering extra-pulmonary involvement. Serum IgG4 levels detected in 48 cases were significantly elevated (307-52 500 mg/L). The radiographic pattern of solid nodule type was the most frequent, accounting for 50.7% (35 cases). A total of 31 (44.9%) patients received glucocorticoid therapy with good response and prognosis. IgG4-related lung disease is a rare immunological disease lack of specific symptoms. Serum immunological examination, radiographic characteristics and histopathology should be comprehensively considered for diagnosis. Glucocorticoid is so far the most acceptable therapy with good response rate.

Computerized tomography-based predictive model for differentiation of Crohn's disease from intestinal tuberculosis.

Intestinal tuberculosis (ITB) and Crohn's disease (CD) have clinical, radiological, endoscopic, and histological resemblance. There is paucity of literature regarding differentiation of CD and ITB based on radiology using computed tomography (CT). The present study was designed to compare CT features of ITB and CD and develop a predictive model to differentiate ITB and CD. Patients with ITB and CD, who underwent CT enteroclysis/CT enterography/CT abdomen before starting treatment, were recruited. Specific findings were noted by a radiologist who was blinded to the diagnosis. A predictive model was developed based on the features which were significantly different in these diseases. Fifty-four patients with CD and 50 patients with ITB were compared. On univariate analysis, left colonic involvement, ileocecal involvement, long-segment involvement, comb sign, presence of skip lesions, involvement of ≥3 segments and ≥1-cm sized lymph nodes were significantly different between CD and ITB. On multivariate analysis, ileocecal involvement, long-segment involvement and the presence of lymph node ≥1 cm were statistically significant. Based upon the latter three variables, a risk score (with values ranging from 0 to 3) was generated, with scores 0 and 1 having specificity of 100 % and 87 %, respectively, and positive predictive values (PPV) of 100 % and 76 %, respectively, for ITB and scores 2 and 3 having specificity of 68 % and 90 %, respectively, and PPV of 63 % and 80 %, respectively, for CD. A predictive model based on the presence of long-segment involvement, ileocecal involvement and lymph nodes sized ≥1 cm on CT could differentiate ITB and CD with good specificity and PPV.

Gastrointestinal Behçet's disease: a review.

Behçet's disease (BD) is an idiopathic, chronic, relapsing, multi-systemic vasculitis characterized by recurrent oral and genital aphthous ulcers, ocular disease and skin lesions. Prevalence of BD is highest in countries along the ancient silk road from the Mediterranean basin to East Asia. By comparison, the prevalence in North American and Northern European countries is low. Gastrointestinal manifestations of Behçet's disease are of particular importance as they are associated with significant morbidity and mortality. Although ileocecal involvement is most commonly described, BD may involve any segment of the intestinal tract as well as the various organs within the gastrointestinal system. Diagnosis is based on clinical criteria - there are no pathognomonic laboratory tests. Methods for monitoring disease activity on therapy are available but imperfect. Evidence-based treatment strategies are lacking. Different classes of medications have been successfully used for the treatment of intestinal BD which include 5-aminosalicylic acid, corticosteroids, immunomodulators, and anti-tumor necrosis factor alpha monoclonal antibody therapy. Like inflammatory bowel disease, surgery is reserved for those who are resistant to medical therapy. A subset of patients have a poor disease course. Accurate methods to detect these patients and the optimal strategy for their treatment are not known at this time.

COMPARISON OF COMPUTERIZED TOMOGRAPHIC AND ULTRASONOGRAPHIC FINDINGS IN ABDOMINAL TUBERCULOSIS

Abstract Introduction: Abdominal TB is very common in third world countries with poor socioeconomic status like Pakistan. Majority of patients end up in intestinal obstruction and other complications and finally under-go surgery. Abdominal tuberculosis may be, enteric, peritoneal, nodal and solid visceral TB or in any com-bination of these four varieties. In some cases, res-ponse to therapeutic trials of anti-tuberculous drugs is the basis of diagnosis that may cause a delay in the diagnosis of other diseases which mimic abdominal tuberculosis. Therefore, diagnosis of abdominal tuberculosis is an ongoing challenge to the physicians, espe-cially with limited resources. Ultrasound and CT are good diagnostic helping tools in diagnosis of abdomi-nal tuberculosis. Objectives: To compare the diagnostic accuracy of Computerized Tomographic and Ultrasonographic findings in Abdominal Tuberculosis considering His-topathology as gold standard. Study Design: Comparative cross sectional. Setting: Department of Diagnostic Radiology, Mayo Hospital Lahore. Duration of Study: Twelve months after the approval of synopsis, from June 2007 to May 2008. Subjects and Methods: 50 patients with clinically suspected abdominal tuberculosis who were candidate for elective surgery were selected. History, examinat-ion and relative investigation were recorded and analy-zed with SPSS version 10. Results: CT is a better modality in finding ileocecal involvement, omentum involvement and para-aortic lymphadenopathy than USG and USG is slightly better in finding mesenteric lymphadenopathy than CT in abdominal tuberculosis. Conclusion: Although none is 100% accurate but there is difference in diagnostic accuracy of compu-terized tomographic and ultrasonographic findings in abdominal tuberculosis. In short combined together, these two modalities can be of great help in pre-opera-tive diagnosis of ATB and in decreasing the mortality and morbidity of the disease. Key words: Abdomen, Tuberculosis, Ultrasono-graphy, Computerized Tomography.

Ileocecal Involvement Is Associated with Increased Severity of Low Rectal Endometriosis

Ileocecal Involvement Is Associated with Increased Severity of Low Rectal Endometriosis

Crohn's disease in a Saudi outpatient population: is it still rare?

Background/Aim:To determine the epidemiology of Crohn's disease (CD) in an outpatient clinic and compare it with data previously reported from different centers in the Kingdom of Saudi Arabia and outside.Materials and Methods:The medical records of all patients with CD seen in the clinic in the period from January 1993 through December 2007 were reviewed. The demographic, clinical data and methods of diagnosis were retrieved.Results:Over a period of 15 years, we saw 133 Saudi patients with CD. They were predominantly young, with a median age of 26.2 years and male preponderance (2.3:1). The final diagnosis was established within 1 week of presentation in 47% of the patients. The leading symptoms were abdominal pain (88%), diarrhea (70%), bloating (61%), rectal bleeding (50%), weight loss (33%), constipation (24%) and perianal disease (23%). The diagnosis was established by endoscopy and histopathology. Ileocecal involvement was encountered in 40% of the patients.Conclusion:From the current study, it is obviously possible to diagnose a large proportion of patients with CD in a gastroenterology outpatient clinic. The data revealed a strikingly increased incidence of CD in a mainly young Saudi population in the past few years.

A Case of Tuberculous Enteritis Mimicking Crohnʼs Disease

Purpose: A 20-year-old Guatemalan male with no significant past medical history presented with complaints of one week of abdominal pain, nausea and vomiting. Labs were unremarkable. A CT scan of the abdomen and pelvis revealed evidence of a small bowel obstruction. After the patient showed no improvement in symptoms with bowel rest and decompression, a small bowel enteroscopy was performed. The enteroscopy showed a stricture within the proximal jejunum, ulcerations distal to the stricture, and diverticulae proximal to the stricture. Biopsies of the ulcerations revealed noncaseating granulomas. Acid fast bacilli (AFB) and fungal stains were negative. Based on the biopsy, there was a concern for the possibility of Crohn's disease so the patient was started on steroids and antibiotics. When the patient did not improve over the next 48 hours, he was referred for a surgical evaluation. A laparotomy revealed the presence of multiple peritoneal nodules, and lysis of adhesions was performed without bowel resection. Biopsies showed caseating granulomas with positive AFB stains. The patient's PPD, HIV test, and chest X-ray were all negative. The patient was started on rifampin, ethambutol, pyrizinamide, and levofloxacin. He showed an improvement in symptoms within six weeks. This case highlights the need for a high index of suspicion for tuberculous enteritis when evaluating patients with possible Crohn's disease, especially HIV patients and immigrants from areas where TB is endemic. Tuberculous enteritis rarely causes a small bowel obstruction. However, in cases where it causes strictures, obstruction is a common complication. Tuberculous enteritis is the most common extrapulmonary manifestation occurring in 25% of patients with pulmonary TB. Although our patient presented with proximal small bowel involvement, the majority of patients (75%) have distal small bowel and ileocecal involvement. As highlighted in this case, diagnosis is often difficult because common screening methods and microbiological diagnostics often fail to detect gastrointestinal TB. However, a prompt diagnosis can help prevent the development of serious complications such as intestinal fistulas, obstruction, and perforations.Figure: Small Bowel Enteroscopy described above

Barium meal follow through with pneumocolon: Screening test for chronic bowel pain

To study the sensitivity, specificity and cost effectiveness of barium meal follow through with pneumocolon (BMFTP) used as a screening modality for patients with chronic abdominal pain of luminal origin in developing countries. Fifty patients attending the Gastroenterology Unit, SMS Hospital, whose clinical evaluation revealed chronic abdominal pain of bowel origin were included in the study. After routine testing, BMFT, BMFTP, contrast enhanced computed tomography (CECT) of the abdomen, barium enema and colonoscopy were performed. The sensitivity, specificity and cost effectiveness of these imaging modalities in the detection of small and/or large bowel lesions were compared. Out of fifty patients, structural pathology was found in ten. Nine out of these ten patients had small bowel involvement while seven had colonic involvement alone or in combination with small bowel involvement. The sensitivity of BMFTP was 100% compared to 88.89% with BMFT when detecting small bowel involvement (BMFTP detected one additional patient with ileocecal involvement). The sensitivity and specificity of BMFTP for the detection of colonic pathology were 85.71% and 95.35% (41/43), respectively. Screening a patient with chronic abdominal pain (bowel origin) using a combination of BMFT and barium enema cost significantly more than BMFTP while their sensitivity was almost comparable. BMFTP should be included in the investigative workup of patients with chronic abdominal pain of luminal origin, where either multiple sites (small and large intestine) of involvement are suspected or the site is unclear on clinical grounds. BMFTP is an economical, quick and comfortable procedure which obviates the need for colonoscopy in the majority of patients.

Abdominal tuberculosis: Imaging features

Radiological findings of abdominal tuberculosis can mimic those of many different diseases. A high level of suspicion is required, especially in high-risk population. In this article, we will describe barium studies, ultrasound (US) and computed tomography (CT) findings of abdominal tuberculosis (TB), with emphasis in the latest. We will illustrate CT findings that can help in the diagnosis of abdominal tuberculosis and describe imaging features that differentiate it from other inflammatory and neoplastic diseases, particularly lymphoma and Crohn's disease. As tuberculosis can affect any organ in the abdomen, emphasis is placed to ileocecal involvement, lymphadenopathy, peritonitis and solid organ disease (liver, spleen and pancreas). A positive culture or hystologic analysis of biopsy is still required in many patients for definitive diagnosis. Learning objectives: 1. To review the relevant pathophysiology of abdominal tuberculosis. 2. Illustrate CT findings that can help in the diagnosis.

Clinicocolonoscopic Differentiation of Tuberculosis From Crohn's Disease

Background: In areas where both tuberculosis and Crohn's disease are common, colonic manifestations may be similar. Despite availability of a battery of tests, it may be difficult to distinguish between these conditions. Aim: To assess clinical features and endoscopy findings that could potentially differentiate colonic tuberculosis from Crohn's colitis. Materials and method: Patients included in this study were those presenting between June 2000 and March 2004 with a definite histologic diagnosis of tuberculosis or Crohn's; or those in whom treatment with anti-tubercular therapy resulted in clinical and/ or endoscopic resolution. These patients were retrospectively reviewed to analyze clinical features and colonoscopic findings Results: 27 patients with colonic tuberculosis and 80 patients with Crohn's disease met the inclusion criteria. Patients with Crohn's disease presented significantly more commonly with diarrhea (83%), rectal bleeding (59%), melena (28%) and prior history of perianal disease (28%). Tubercular patients tended to have abdominal pain more commonly (96%). On colonoscopy of tuberculosis patients, contiguous ileocaecal involvement was significantly more common (74%) and left colon involvement significantly less common. The ulcerations tended to be transverse. On the contrary, skip lesions, rectal and left colonic involvement and linear ulcers were significantly more common in Crohn's disease. Conclusion: Clinical presentation with diarrhea, rectal bleed or malena, previous history of perianal disease and colonoscopic left colonic involvement, skip lesions and linear ulcers are more commonly seen in Crohn's disease. Patients presenting predominantly with abdominal pain and colonoscopic features of ileocecal involvement are more often seen in colonic tuberculosis. Background: In areas where both tuberculosis and Crohn's disease are common, colonic manifestations may be similar. Despite availability of a battery of tests, it may be difficult to distinguish between these conditions. Aim: To assess clinical features and endoscopy findings that could potentially differentiate colonic tuberculosis from Crohn's colitis. Materials and method: Patients included in this study were those presenting between June 2000 and March 2004 with a definite histologic diagnosis of tuberculosis or Crohn's; or those in whom treatment with anti-tubercular therapy resulted in clinical and/ or endoscopic resolution. These patients were retrospectively reviewed to analyze clinical features and colonoscopic findings Results: 27 patients with colonic tuberculosis and 80 patients with Crohn's disease met the inclusion criteria. Patients with Crohn's disease presented significantly more commonly with diarrhea (83%), rectal bleeding (59%), melena (28%) and prior history of perianal disease (28%). Tubercular patients tended to have abdominal pain more commonly (96%). On colonoscopy of tuberculosis patients, contiguous ileocaecal involvement was significantly more common (74%) and left colon involvement significantly less common. The ulcerations tended to be transverse. On the contrary, skip lesions, rectal and left colonic involvement and linear ulcers were significantly more common in Crohn's disease. Conclusion: Clinical presentation with diarrhea, rectal bleed or malena, previous history of perianal disease and colonoscopic left colonic involvement, skip lesions and linear ulcers are more commonly seen in Crohn's disease. Patients presenting predominantly with abdominal pain and colonoscopic features of ileocecal involvement are more often seen in colonic tuberculosis.