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Granulomatosis Colitis

Granulomatosis Colitis. Presented by Dr. Leon Wolf. History . C.C. Anemia and HO + 45 yo male asymptomatic PMH h/o goiter, Rx Synthroid FH CAD DM Colonic polyps SH born outside of USA, postal worker ROS w/o wt loss, fever w/o cough, sputum hemoptysis. Physical Exam.

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Granulomatosis Colitis

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  1. Granulomatosis Colitis Presented by Dr. Leon Wolf

  2. History • C.C. Anemia and HO + • 45 yo male asymptomatic • PMH h/o goiter, Rx Synthroid • FH CAD DM Colonic polyps • SH born outside of USA, postal worker • ROS w/o wt loss, fever w/o cough, sputum hemoptysis

  3. Physical Exam • Healthy appearing wt.220 T.98.6 • HEENT R. neck fullness • Lungs clear • Abd soft w/o masses, LSKK • Rectal w/o masses, HO+ • Ext w/o joint fullness or tenderness • Skin w/o rashes

  4. LAB • Hgb 10.6, MCV 77 • WBC 8,900 ; normal differential • CMP normal • CEA 1.4

  5. ENDOSCOPIC EVALUATION • Colon cecal villous,nodular friable lesion • EGD gastric erythema esophageal nodule • Microscopic Colon: granulomatous colitis Stomach: mild gastritis Esophagus: papilloma

  6. Clinical Course • RX Pentasa, iron • CXR negative • SBFT negative • CTABD/PELVIS negative • PPD positive 20yrs ago

  7. Re-Colonoscopy • Villous, nodular lesion • Open ileocecal valve • Ileal lymphoid hyperplasia • Cultures AFB,Fungus, O&P • Stains

  8. Gastrointestinal diseases Inflammatory bowel disease Crohn’s disease Ulcerative colitis Nodular lymphoid hyperplasia Celiac disease Necrotizing enterocolitis Gastrointestinal diseases continued Behçet’s disease Eosinophilic gastroenteritis Hirschsprung’s disease with necrotizing enterocolitis Neoplasms Anatomical or vascular abnormalities Diseases to Consider in the Differential Diagnosis

  9. Hematologic diseases Chronic granulomatous disease Langerhans’ –cell histiocytosis Familial hemophagocytic lymphohistiocytosis Systemic inflammatory diseases Sarcoidosis Wegener’s granulomatosis Juvenile dermatomyositis Juvenile rheumatoid arthritis Systemic lupus erythematosus Diseases to Consider in the Differential Diagnosis Continued

  10. Diseases to Consider in the Differential Diagnosis continued • Infectious diseases • Mycobacterium tuberculosis infection • M. avium infection • Yersinia infection • Giardia lamblia infection • Tropheryma whippelii infection • Bartonella henselae infection

  11. Differential DX • Yersinia • Sarcoidosis • Crohn’s disease • Tuberculosis

  12. Yersinia • Gram negative rod • Contaminated milk, milk products • Acute manifestations • Enterocolits most common <5 yo • Adenitis, ileitis >5 yo • Bacteremia in pts underlying disease • Reiter’s syndrome • Self limited 3 to 4 wks

  13. Sarcoidosis • Gastrointestinal involvement uncommon other than liver granulomatosis • Stomach primarily,bleeding ulcerations • Small intestine nodal or lymphatic blockage • Esophageal obstruction lymph nodes or infiltration • Pulmonary or renal involvement with above

  14. Tuberculosis • Koch 1882 ID bacillus • Primary pulmonary disease • Pre antiboitics 55-90% GI involvement • Proportional to pulmonary disease • Post antiboitics GI disease have <50% pulmonary tb evidence

  15. Tuberculosis organisms • M. tuberculosis • M.bovis • (M. avium)

  16. Patients At Higher Risk • Immigrants (travel endemic areas) • AIDS • Urban poor • Living on reservations • Prisoners • NH residents

  17. Gastrointestinal Areas • Ileocecal/ileal approx 75% • Asc.colon appendix approx 20% • Uncommon jejunum,stomach,esophagus, sigmoid/rectum, anal • Multiple areas-skip areas

  18. Clinical Sx and Exam • Non-specific sx 80-90% pain wt loss diarrhea/constipation blood in stools • PE abdominal mass perianal lesions

  19. Complications • Hemorrhage • Perforation • Obstruction • Fistula formation • Malabsorption

  20. Endoscopic Findings • Ulcerative 60% • Hypertrophic 10% • Mixed 30% • Circumferential ulcers • Scarred open IC valve

  21. Radiological Findings • BE/SBFT ulcers thickening/distortion stenosis pseudopolyps • CT adenopathy-central necrosis mass calcified nodes

  22. Diagnosis • Stain <20% • PCR 80% • Culture <30% mucosal biopsies ? % surgical specimen esp node n.g. stool esp with pulm disease • Presumptive +PPD, +CXR • Therapeutic Response

  23. Clinical Course • Iron RX increase hgb felt less dizzy • + AFB culture • M.gordonia

  24. Ten Diseases Doctors Miss Reader’s Digest Feb 2003 • Hepatits C • Lupus • Celiac Disease • Hemochromatosis • Aneurysm • Lyme Disease • Hypothyroidism • Polycystic Ovary Syndrome • Chlamydia • Sleep Apnea

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