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Case Presentation • A 31 years-old female patient has been complaining about loose and watery , non-bloody stools for at least 6 weeks , with a crampy abdominal pain localized mostly at the peri umbilical area, and weight loss. In addition during the last weeks a new, even worse back pain has been troubling her , specially in the morning with a sensation of back stiffness. • Physical Examination : unremarkable, except a mild tenderness at the RLQ Jorge Delgado, MD. Department of Gastroenterology.
Investigations • Routine Stools analysis for parasites and Bacteria were negatives • Micro-Hypo anemia was found as well as a striking Alkaline Phosphatase elevation • Anti EM and anti tTG antibodies were negatives • A lumbar X Ray was done • A sigmoidoscopy and a Small Bowel Follow through were indicated Jorge Delgado, MD. Department of Gastroenterology.
Sacroiliitis and ankylosing spondylitis demonstrating obliteration of the sacroiliac joints (large arrow) and bamboo spine with syndesmophytes (small arrow) Jorge Delgado, MD. Department of Gastroenterology.
Crohn’s Disease (CD) • Crohn's disease is a disorder of uncertain etiology that is characterized by transmural mucosal inflammation. The transmural inflammatory nature of Crohn's disease often leads to fibrosis and to obstructive clinical presentations .The transmural inflammation can also result in sinus tracts that burrow through and penetrate the serosa, giving rise to microperforations and fistulae Jorge Delgado, MD. Department of Gastroenterology.
CD. Obstructive Form • Obstructive disease is the result of inflammation narrowing the intestinal lumen and obstructing the flow of intestinal contents. Over time, fibrosis and thickening of the intestinal wall also contribute to obstruction. • Crampy abdominal pain, nausea, vomiting, and diarrhea are the major symptoms associated with obstructing disease. Jorge Delgado, MD. Department of Gastroenterology.
CD. Fistulizing\ Penetrating Form • Fistulizing disease occurs when the inflammatory process extends completely through the intestinal wall. The escape of bacteria through these defects in the wall can result in abscesses. Extension of the inflammatory process into adjacent organs results in fistulae (enteroenteric, enterocutaneous, enterovesicular, etc.). Fistulizing disease can present with fever, leukocytosis, and evidence of fistulization (e.g., enterocutaneousfistulae). Jorge Delgado, MD. Department of Gastroenterology.
CD. Penetrating The actual clinical manifestation of the fistula depends on the area of involvement adjacent to the diseased bowel segment. • Enteroentericfistulae may be asymptomatic or present as a palpable mass • Enterovesicle (Bladder) Fistulae lead to recurrent urinary tract infections often with multiple organisms and to a complaint of pneumaturia • Fistulas to Retroperitoneum lead to Psoas Abscess and Ureteral Obstruction with hydronephrosis • Enterocutaneous fistulae cause the obvious cosmetic problem of bowel contents draining to thesurface ofthe skin. Jorge Delgado, MD. Department of Gastroenterology.
Physical Examination.CD • When the disease is active, the patient looks pale, weak, and chronically ill. Aphthous ulcers in the mouth are common in active Crohn’s disease. • The abdomen may be tender, typically over the area of disease activity. Thickened bowel loops, thickened mesentery, or an abscess may cause a sense of fullness or a mass, often in the right lower quadrant. Rebound tenderness (most often referred) is often present. Fistulous openings, induration, redness, or tenderness near the anus suggest the presence of perianal Crohn’s disease. The mucosa at the anal verge may appear purplish because of vascular engorgement. Fissures in the anal canal can occur Jorge Delgado, MD. Department of Gastroenterology.
