ד"ר דוד ירדני המכון לגסטרואנטרולוגיה ומחלות כבד מרכז רפואי סורוקה

Transcription

1 ד"ר דוד ירדני המכון לגסטרואנטרולוגיה ומחלות כבד מרכז רפואי סורוקה

2 Presentaion: S.A is 38 years old. Referred for rectal bleeding investigation. Describes several occasions of bleeding and abdominal pain. The patient relates the pain to her period. The pain subsides under OCP Rx. Proctologic examination reveals only minor hemorrhoids.

3 Past medical history: Recently treated for PID. Endometriosis.

4 Lab (1): Hb MCV- 63.1, MCH RDW WBC- 6.57K PLT- 370 Ferritin- 10 Iron- 23 Transferrin- 405, Sat%- 4.4

5 Lab (2): Cr Na- 139, K- 4.8 BILIRUBIN- 0.3 ALK.PHOS- 51 GOT- 22 GPT- 13 Albumin- 3.6 Globulin- 3.1

6 Lab (3): CRP- 0.9 Celiac screen- Negative. The patient was referred for an investigational colonoscopy

7 Colonoscopy: A tumor was observed in the cecum protruding from the ileocecal valve that prevented ileocecal intubation. Biopsies were performed

8 What s next?

9 Abdominal CT scan: A CT scan demonstrated both thickening of the terminal ileum wall and a mass involving the terminal ileum and cecum

10 Pathology report: inflammatory tissue

11 Repeat colonoscopy with partial resection: inflammatory tissue

12 DD: Infectious IBD Carcinoma Lymphoma Hyperplastic polyp

13 Infectious: Stool culture positive for Campylobacter. Patient was treated with a partial antibiotic course of Azithromycin followed by a complete Cipro Rx.

14 Repeat stool culture: NEGATIVE! What s next? Further diagnostic workup is ordered: MRE Repeat CRP Serologly for amebiasis

15 But the patient arrives to the ER with severe abdominal pain No change in blood tests, discharged home. What s next??

16 Due to the size of the mass and to exclude malignancy, the patient undergoes right hemicolectomy

17 From the surgeon s report: creeping fat and an inflamed terminal ileum were observed

18 Pathology report: The pathology revealed an inflammatory fibroid polyp. The surrounding mucosa was inflamed with features suspicious of Crohn s ileitis.

19 Characteristic pathology of IFP. Plate A showing broadening of the submucosal layer. Plate B showing prominent capillaries and plate C showing eosinophilic infiltrate..

20 Inflammatory fibroid polyps: Inflammatory fibroid polyps (IFP) of the gastrointestinal tract were first described by Vanek in 1949.

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22 Inflammatory fibroid polyps: These are rare benign submucosal polyps arising from mesenchymal cells and can occur anywhere along the GI tract but are commonest in the stomach, followed in frequency by the small bowel. Because of its narrow lumen and is susceptibility to intussusception by masses that serve as lead points, the typical presentation of ileal IFP is small bowel obstruction. Rarely IFP co-occurrs with Crohn s disease and the presentation is that of small bowel obstruction

23 Back to the patient: Post-surgery the patient complained of diarrhea and low back pain that was diagnosed as sacroiliitis. Repeat colonoscopy revealed Crohn s disease recurrence of the neoterminal ileum with Rutgeerts score i2: more than five aphthous lesions with normal intervening mucosa, skip areas of larger lesions or lesions confined to ileocolonic anastomosis (ie, less than 1 cm in length).

24 And finally: A short course of steroids and the initiation of Azathioprine brought the patient into remission with mucosal healing

25 Discussion: We present here a newly-diagnosed Crohn s disease patient with an inflammatory fibroid polyp of the terminal ileum at presentation. Small bowel obstruction or intussusception was not present. Postoperatively the patient went on to have classic symptoms of postoperative Crohn s disease recurrence including diarrhea, elevated CRP and endoscopic features of neoterminal ileal disease.

26 To date 9 cases have reported the association of IFP with Crohn s disease. The previously reported cases had similar ileal location of the IFP and, unlike our patient, an obstructive clinical presentation. There were three reported IFP cases in ulcerative colitis patients all of them were post colectomy patients presenting with obstructive features and the occurrence was in the ileum in the constructed pouch.

27 Conclusion: Inflammatory fibroid polyps of the terminal ileum can present in Crohn's disease patients without intestinal obstruction. Surgical treatment is the rule and postoperatively disease recurrence is common as for other Crohn's disease patients.

28 תודה רבה