Initial Presentation Of Crohn Research Articles

Case Report: Acute peritonitis inaugurating Crohn's disease with spontaneous perforation in the peritoneal cavity

Background: Crohn's Disease is a chronic, idiopathic, and transmural inflammatory condition that mainly affects the distal ileum. It is characterized by intricate pathophysiology and numerous complications, some of which can be fatal. In this report, we present a case study of acute generalized peritonitis resulting from the perforation of a distal ileal loop, inaugurating the diagnosis of Crohn's disease. Case presentation: A 43-year-old patient presented with a clinical presentation of acute peritonitis. He had a one-year history of intermittent abdominal pain and diarrhea. As the maximum pain was in the right iliac fossa, an acute appendicitis complicated with peritonitis was considered and the patient underwent laparoscopic exploration, without morphologic exploration. Peroperative observation found an inflamed conglomerate of small bowel loops associated with sclerolipomatosis, and purulent peritonitis by perforation of a distal ileal loop, 40 cm from the ileocaecal valve. A peritoneal toilet, ileocaecal resection, and ileo-colostomy were performed. The postoperative course was uneventful. Discussion: Various complications may arise during the evolution of Crohn’s disease. However, fatal complication such as generalized peritonitis leading to the diagnosis is rare. The underlying pathophysiology of free perforation remains unknown. The most common site affected is the terminal ileum. The surgical treatment is based on a limited resection of the affected bowel segment, followed by a temporary stoma. A primary anastomosis can be performed in selected patients. Conclusion: Perforative peritonitis as an initial presentation of Crohn's disease is challenging. Surgery is obviously required for acute peritonitis, with limited resection with or without anastomosis.

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

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.

Perforated ileum as the initial presentation of Crohn's disease, a case report.

IntroductionThe perforation of the bowel as the first presentation of inflammatory bowel disease is a rare occurrence reported in about 0.15–3 % of the literature and is especially unusual in young patients <30 years of age. It is a serious event with most of the perforations occurring on the ileum. This article describes a unique case of a 20-year-old female patient who presented with perforated ileum due to Crohn's disease as an initial presentation operated at a private surgical center.Case presentationWe present a case of a previously asymptomatic 21-year-old female presenting with intestinal perforation secondary to Crohn's disease for the first time.The patient presented with crampy abdominal pain and frequent bilious vomiting of 3 days duration. She also had a high-grade fever and abdominal distension. WBC was 24,000 and an abdominal CT scan showed perforation of the bowel consistent with Crohn's Disease. Ruling out other etiologies perforated viscous secondary to query Crohn's Disease was entertained and laparotomy revealed 2 × 2 cm perforation on the anti-mesenteric border of the terminal ileum. The perforated segment was resected primary anastomosis was performed.Following surgery, the patient was discharged symptom-free and linked to the Gastroenterology unit after a biopsy confirmed Crohn's disease. She was started on Prednisolone and Azathioprine exactly a month after her surgery. Her 6-month follow-up is smooth.ConclusionPresentation of bowel perforation as an initial feature of Crohn's Disease is a rare phenomenon. Adequate resuscitation followed by emergency laparotomy with primary resection and anastomosis could be life-saving for a hemodynamically stable patient.

A197 ACUTE ILEITIS IN ADULT PATIENT: A RETROSPECTIVE STUDY OF PATIENT OUTCOMES

BackgroundRising availability of medical imaging exams in the emergency room potentially leads to an increase of ileitis findings by imaging in a context of gastrointestinal symptoms. However, it can be difficult to determine the clinical significance of this radiological finding in an acute consultation setting and to establish the relevant investigations.AimsThe aim of this study is to describe the current management and the long-term outcome of patients with diagnostic of acute ileitis on imaging during an emergency consultation in our center, Centre Hospitalier Universitaire de Sherbrooke(CHUS).MethodsWe performed a retrospective study of all patients diagnosed with ileitis by abdominal ultrasound or computed tomography (CT scan) during a visit in our emergency department over the years 2010 and 2017. Patients with previous diagnosis of Crohn disease were excluded. Data collected were clinical, radiological and endoscopic at diagnostic and over at least 3 years following the initial visit.ResultsA total of 118 files were reviewed. The initial imaging modality was 43% ultrasound and 57% CT scan. 36% of patients had an ileocolonoscopy within one month of the initial visit. Of these, 60% demonstrated macroscopic endoscopic abnormalities. 51% of patients had follow-up imaging within 3 months of the initial consultation. 64% of these images demonstrated persistence of pathological changes in the ileal region. Only 48% had a stool culture at diagnosis. 72% of patients met a gastroenterologist and 45% saw a general surgeon. The most common cause of ileitis was an infectious origin at 44% predominantly with Yersinia enterocolitica and Campylobacter jejuni. 13% received a diagnostic of Crohn disease. 20% of ileitis remained undetermined. Among these, there was a case of Crohn’s disease which was eventually diagnosed 2 years later. The initial factors associated with a diagnosis of Crohn’s disease were family history of inflammatory bowel disease (OR 6.17 95% CI 1.67 to 22.781 p = 0.006), extra-digestive manifestations (OR 23.31 95% CI 2.255 to 240.92 p = 0.008), discontinuous impairment at initial imaging (OR 19.8 95% CI 4.284 to 91.52 p = 0.000), presence of stenosis at initial imaging (OR 14.429 95% CI 1.227 to 169.68 p = 0.034), the presence of abscess or collection on imaging (OR 11.54 95% CI 1.76 to 75.63 p = 0.011) and wall thickness in mm (1.22 95% CI 1.06 to 1.40 p = 0.005).ConclusionsOur study shows that the majority of acute ileitis found on imaging are of infectious origin. A portion of acute ileitis corresponded to the initial presentation of Crohn’s disease. Thus, we believe that it is preferable to offer at least clinical follow-up to patients with acute ileitis on imaging and to consider additional investigation by imaging and / or colonoscopy when symptoms persist and this particularly in presence of factors associated with Crohn’s disease.Funding AgenciesNone

Lip Swelling as Initial Presentation of Crohn’s Disease

A 31-year-old woman presented with a year of recurrent lower lip swelling with associated oral ulcers (Figure A). Labs were notable for an elevated C-reactive protein and hypoalbuminemia. A punch biopsy of her lower lip showed granulomatous dermatitis with lymphangiectasia, and she was given the diagnosis of orofacial granulomatosis (Figure B). Resolution of symptoms only occurred with chronic prednisone. Subsequent onset of abdominal pain, diarrhea, and bright red blood per rectum prompted a full gastrointestinal (GI) workup for possible Crohn’s disease (CD).

S2398 Lip Swelling as Initial Presentation of Crohn's Disease

S2398 Lip Swelling as Initial Presentation of Crohn's Disease

Calculation of the Lémann index at initial presentation of Crohn's disease in a sample of Iraqi patients attending gastroenterology and hepatology teaching hospital.

Crohn's disease (CD) is a chronic inflammatory disorder that may involve any part of the alimentary tract from mouth to anus and is characterized by periods of clinical remission alternating with periods of recurrence. Current clinical and endoscopic indices only measure disease activity at a specific time point. The recently published Lémann index (LI) is the first tool that aims to measure cumulative structural bowel damage and thus evaluates long-term disability. To measure the LI at initial presentation of CD in a sample of Iraqi patients attending the gastroenterology and hepatology teaching hospital (Baghdad). This is a descriptive single-center study conducted in gastroenterology and hepatology teaching hospital and enrolled 30 patients with CD diagnosed from 2013 to 2015. They all underwent complete physical examination, abdominopelvic CT scan, upper endoscopy, and colonoscopy upon diagnosis for the purpose of assessing bowel damage by the LI. For the 30 patients included, median LI was 1.3 (range 0.2-12.6). The LI is now available and it enables, for the first time, assessment of bowel damage in CD.

2070 Sweet's Syndrome as the Initial Presentation of Crohn's Disease

INTRODUCTION: The diagnostic criteria for Sweet's syndrome include fever, peripheral neutrophilia, erythematous skin lesions and diffuse neutrophilic dermal infiltrate. Classically, the lesions and symptoms promptly improve with the initiation of systemic corticosteroids. This is a rare case of Sweet’s syndrome as the initial presentation of Crohn’s disease. CASE DESCRIPTION/METHODS: A 23-year-old African-American male with no past medical history presented to our ED with fever and rash. He reported a sudden onset mildly sensitive rash on his bilateral lower extremities, preceded by two weeks of fever, myalgia and headaches. He denied arthralgia but endorsed recent weight loss and sporadic aphthous ulcers. He developed watery, non-bloody diarrhea in the ED. His abdomen was soft and non-tender. Examination of the rash revealed erythematous nodules, some studded with pustules and a few ulcerated nodules. He was febrile to 102.7 ºF with tachycardia. Labs were significant for leukocytosis at 22.5 (68% neutrophils), thrombocytosis at 515, microcytic anemia (Hb 9.6), elevated inflammatory markers (CRP 326 mg/L; ESR &gt;130 mm) and AST:ALT 64:41 U/L. Broad spectrum antibiotics were started due to concerns for sepsis. Blood, wound, and stool cultures, including Clostridium difficile were all negative. Fecal calprotectin was 32. His immunological workup showed ANA, RF and anti-GBM negative; normal IgM, IgG, IgA, C3 and C4. HIV, Hepatitis B and C and QuantiFERON were also negative. ANCA was positive at 1:320, with positive PR3. CT scan of the abdomen showed proctitis and ascending colitis with no lymphadenopathy. Colonoscopy showed mild-moderate inflammation of the left sided colon with skip lesions in the transverse colon, without terminal ileum involvement, with biopsies showing focal acute cryptitis and rare crypt abscesses. Skin biopsy revealed neutrophilic dermatitis and panniculitis without vasculitis. Once infection was ruled out, prednisone 60 mg was started and the rash and fever rapidly improved. DISCUSSION: Sweet’s syndrome is considered part of the family of neutrophilic dermatoses, which also includes pyoderma gangrenosum, and is considered an unusual extra-intestinal manifestation of IBD. Sweet's syndrome is also associated with malignancies, infections, pregnancy and medications. The temporal relationship between Sweet's syndrome and IBD activity is variable, but the majority of cases present after the diagnosis of IBD, with few cases in the literature with Sweet’s syndrome as the presenting symptom for IBD.

1519 Portal Vein Thrombosis as an Initial Presentation of Crohn's Disease

INTRODUCTION: Inflammatory bowel diseases (IBD) are chronic and progressive conditions that can increase the risk of thromboembolism, including portal vein thrombosis (PVT). PVT are exclusively described in cases with confirmed IBD diagnosis and are more commonly related to ulcerative colitis. This report highlights a case of PVT as an initial manifestation of Crohn's disease. CASE DESCRIPTION/METHODS: A 38-year-old gentleman presented with worsening abdominal pain, watery diarrhea and weight loss of the last three months. His initial diagnosis was diverticulitis and a course of oral ciprofloxacin was prescribed. As symptoms persisted, a colonoscopy was performed and showed diverticulitis in the descending colon. The pathology demonstrated acute cryptitis from rectum to cecum. Due to ongoing symptoms, a computed tomography (CT) of the abdomen without contrast was obtained and showed wall thickening and inflammatory changes in the small bowel. Despite another course of antibiotics with the addition of oral steroids, his pain worsened and thus repeat imaging was performed as an abdominal CT with contrast. He was found to have a chronic PVT extending into the superior mesenteric vein (SMV) and was transferred to our institution for further management. Physical exam was notable for mild tenderness in upper abdominal quadrants. Laboratory studies revealed mildly elevated CRP and ESR but his liver function was normal. Hematologic workups including hypercoagulability and clonal disorders were noncontributory. He endorsed a history of tobacco abuse, but no history of abdominal surgery nor family history of IBD. A CT enterography showed skip lesions suggestive of Crohn's enteritis along with thrombus in the right main portal vein and SMV. The pathology report from a repeat colonoscopy showed chronic active colitis. The patient then improved with high dose oral steroids and he was discharged on a tapered steroid regimen with oral anticoagulation. Follow-up appointments were scheduled with hematology and gastroenterology. DISCUSSION: In summary, this case represents one of the handful reported cases of PVT being the initial presentation of Crohn's disease. In those with an established IBD diagnosis, PVT should be considered with persistent abdominal pain in the absence of active inflammation. Early recognition of portal vein thrombosis may expedite treatment and prevent the consequences of portal hypertension.

An Uncommon Initial Presentation of Crohn’s Disease Complicating a Multi-gestation Pregnancy [26G

An Uncommon Initial Presentation of Crohn’s Disease Complicating a Multi-gestation Pregnancy [26G

Pelvic Abscess with Initial Presentation of Crohn’s Disease in Pregnancy Leading to Maternal Sepsis

Background: A new diagnosis of Crohn disease during pregnancy is uncommon. Intra-abdominal abscess as an initial feature of Crohn disease during pregnancy is rare. Case: A 26-year-old healthy primigravida woman at 33 weeks of gestation presented with abdominal pain and an abdominal mass. Labor was induced at 37 weeks to expedite postpartum evaluation. On postpartum day 2 she developed septic shock and multiorgan failure. Emergent exploratory laparotomy revealed an intra-abdominal abscess involving the right colon and terminal ileum. Pathology was consistent with Crohn’s disease. Conclusion: Intra-abdominal abscess from Crohn’s disease is a rare occurrence during pregnancy and may be associated with significant maternal morbidity. When diagnosis in the postpartum period is uncertain and the differential diagnosis includes Crohn’s disease or abscess, early postpartum evaluation may prevent complications.

Acute Pancreatitis as Initial Presentation of Crohn’s Disease: Report of a Rare Case

Introduction: Acute pancreatitis related to Crohn’s disease (CD) has rarely been reported, but whether a causal association exist remains unclear. Forgut CD occurs in 0.5-4% of patients with ileocolonic CD. The pathogenesis of pancreatitis in CD seems to be multifactorial. We sought to describe a case of acute pancreatitis before the establishment of CD. Methods: A 19-year-old African American male with history of hypertension was admitted to our hospital for sharp epigastric abdominal pain of 10 days duration and 10 Ibs of weight loss. He presented 1 year previously with similar pain and was diagnosed with peptic ulcer disease, confirmed with an upper endoscopy. Omeprazole was prescribed, which he has been taking since then. He denied smoking, drinking alcohol, and using NSAID or recreational drugs. No drugs known to be involved in the causation of pancreatitis were taken by the patient. He was found to have lipase of 3,000 but normal liver chemistry, triglyceride, calcium, IgG4, and anti-neutrophilic antibody. Abdominal ultrasound ruled out gallstone or any biliary dilation, whereas abdominal CT revealed mild dilation of stomach, narrowing of second part of the duodenum, and changes consistent with acute pancreatitis, though no pseudocyst and mass were noted. Classical treatment strategies including food restriction, fluid, and electrolyte restoration were sought. Further investigation with an upper esophagogastroduodenoscopy was performed to determine the cause of the duodenal narrowing, which revealed moderate ulceration in duodenal bulb with mild post-bulbar stenosis. Biopsies showed fibrinopurulent exudate consistent with ulcer, with no evidence of Helicobacter pylori infection. Results: He responded to conservative therapy. Given his young age, concern regarding duodenal CD was raised. He subsequently underwent MR enterography, which showed a moderate degree of thickness and narrowing of terminal ileum. Colonoscopy was performed, which showed aphthous-like ulcers in the ileocecal valve, a moderate degree of erythema, and edema scattered throughout the colon. Histology was consistent with inflammatory infiltration of lamina propria and granulomas. Treatment with certolizumab pegol was initiated. He had total resolution of his abdominal pain and Harvey Bradshaw score of zero in 3-month clinic follow-up. Discussion: Patients with inflammatory bowel disease are prone to develop acute pancreatitis with numerous possible etiologies. In the present case, duodenal involvement was likely the predisposing factor. Search for etiological factors should focus attention on serious side effects of medical treatment, morphological abnormalities in the upper GI tract, gallstone, sclerosing cholangitis, and extra intestinal manifestation. Disclosure - Dr. Sarah Glover - Advisory Committee: Abbvie, Grant/Research Support: Biogen, Bristol Myers Squibb, Celgene, Elan, Janssen, Pfizer and UCB.

Jejunal perforation: An unusual presentation of Crohn's disease

Introduction: Spontaneous perforation of the small intestine is a well­documented initial presentation or complication of Crohn’s disease. Review of literature shows that the most common site of free perforation is the ileum. Transmural inflammation of the intestinal walls makes them more susceptible to insult. Perforation of the jejunum as the initial presentation in Crohn’s disease is rare and not well described in literature. Case Report: We report a case of spontaneous jejunal perforation in a 34­year­old Caucasian male. Histopathological studies revealed Crohn’s disease. Conclusion: Our case brought to light an uncommon presentation of this disease. Isolated jejunal perforation as an initial presentation of Crohn’s disease is very rare. Prompt identification of this complication is essential in patients with Crohn’s disease and early referral for surgery is warranted.

A Case of Acute Myocarditis as the Initial Presentation of Crohn's Disease

We experienced a case of acute myocarditis as the initial presentation of Crohn's disease. A 19-year-old woman was admitted with impaired consciousness, shock, and respiratory failure. She had suffered from frequent diarrhea and abdominal pain for several years. Cardiac troponin I and creatine kinase-MB fraction levels were elevated to 5.32 and 16.66 ng/mL, respectively. A 12-lead electrocardiogram showed sinus tachycardia, and a chest radiograph revealed interstitial pulmonary edema. An echocardiogram showed dilated ventricles with akinesia of the basal to apical inferoseptal, anteroseptal, anterior, and inferior left ventricular walls and severely impaired systolic function. Intensive care with inotropic support was effective, and her clinical condition gradually improved. Two weeks later, a colonoscopy revealed ulceration with stenosis in the terminal ileum and multiple aphthous ulcers in the rectum. A biopsy of the rectum revealed non-caseating granulomatous inflammation. She was diagnosed with Crohn's disease presenting with acute myocarditis.

Sternoclavicular Joint Arthritis as the Initial Presentation of Crohn’s Disease in an Adolescent

Sternoclavicular Joint Arthritis as the Initial Presentation of Crohn’s Disease in an Adolescent

Crohnʼs Disease Presenting as Acute Colonic Obstruction Secondary to CMV in an Immunocompetent Patient

Purpose: CMV colitis has been associated with inflammatory bowel disease (IBD). We report a case of a patient with large bowel obstruction who was found to have active CMV infection and later on was diagnosed with Crohn's disease. Methods: A 70-year-old male with DM, hypertension and prostate cancer was admitted with fever, severe abdominal pain, distension, nausea and vomiting. Physical examination revealed a diaphoretic, febrile, tachycardic male who was not in respiratory distress. The abdomen was distended and diffusely tender. Results: Labs showed a hemoglobin of 12.9 g/dL, WBC 23.4 K/mcL. Venous pH 7.26, lactic acid 9.4 mml/L. Stool and blood cultures were negative. Abdominal CT scan showed dilated colon, wall thickening and a narrowing area in the sigmoid colon concerning for a transitional zone. Emergent laparotomy was done for possible malignant large bowel obstruction. Laparotomy demonstrated a large obstructive sigmoid tumor. Patient underwent sigmoidocolectomy, with creations of a hartman's pouch and an end colostomy. Histology of the resected specimen suggested benign stricture with fibrosis, transmural inflammation and widespread mucosal ulcerations. He had intermittent fever post surgery despite treatment with immipenam, vancomycin, tigecycline and fluconazole. Multiple blood and urine cultures were negative. A repeat CT showed pan colitis. Colonoscopy was performed and biopsy revealed inflammation and acute CMV colitis. HIV testing was negative. Gancyclovir IV was administered for 4 weeks. The patient's clinical status improved. A repeat colonoscopy was done 6 months after discharge, histology revealed illietis and pan colitis without CMV present. A diagnosis of Crohn's disease was made and asacol treatment was started. Another repeat colonoscopy done 9 months later showed improvement of inflammation. Conclusion: CMV colitis is rare in immunocompetent patients and sometimes it is associated with IBD. On rare occasions, it can mimic colon carcinoma. In our case, obstructive CMV was the initial presentation of Crohn's disease. Elevated cytokines such as TNF-α, IFN-γ, IL-6 might be involved in reactivation of latent CMV infection which in turn exacerbates IBD. Others have suggested primary CMV infection precipitates IBD by enhancing surface antigen expression in a host predisposed to IBD. Standard treatment for CMV colitis is under debate since it is usually a self-limiting event. In our case, patient improved clinically after starting ganciclovir treatment. Ganciclovir treatment should be considered in patients who are at a higher mortality rate including those over 55 years old, and those with diabetes, renal failure, pregnancy or untreated non-hematological malignancy.

Exudative ascites as initial presentation of Crohn's disease: a case report

Exudative ascites as initial presentation of Crohn's disease: a case report

Crohn’s fistula: current concepts in management

Crohn’s disease was described in 1932 in the classic article by Crohn et al., and then subsequently the authors described one of the disease complications, namely perianal fistula. It was originally thought that the perianal disease originated in the inflamed terminal ileum, which extended internally down to the perianal area. In the last 70 years, we have learned much about this disease, as well as the complications of both perianal and internal fistula. Approximately 60%–70% of all patients with Crohn’s disease will eventually need to undergo surgery, which in many cases is related to the development of a perianal fistula, subsequent to an abscess.1 The purpose of this article is to review our current knowledge of Crohn’s fistula, focusing predominantly on the concepts in clinical management.

Pancreatitis crónica como presentación inicial de la enfermedad de Crohn

It has been suggested that pancreatitis could be an extrahepatic manifestation of inflammatory bowel disease, since its incidence in this disease is greater than that in the general population and in many cases no etiological factor is found. We present a case of chronic idiopathic pancreatitis as the initial presentation of Crohn's disease of the colon.

Ascites associated with the initial presentation of Crohn’s disease

We report a case of a 23-yr-old patient who was initially admitted with severe Crohn’s ileocolitis complicated by a large amount of exudative ascites. There was no evidence of malignancy, portal hypertension, or inflammation in any organ other than the bowel. We present the clinical course and response to treatment and discuss the possible mechanisms by which Crohn’s disease might contribute to the development of exudative ascites.