Transcript Granulomatosis Colitis

Granulomatosis Colitis
Presented by
Dr. Leon Wolf
History
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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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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
LAB
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Hgb 10.6, MCV 77
WBC 8,900 ; normal differential
CMP normal
CEA 1.4
ENDOSCOPIC EVALUATION
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Colon cecal villous,nodular friable lesion
EGD gastric erythema
esophageal nodule
Microscopic Colon: granulomatous colitis
Stomach: mild gastritis
Esophagus: papilloma
Clinical Course
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RX Pentasa, iron
CXR negative
SBFT negative
CTABD/PELVIS negative
PPD positive 20yrs ago
Re-Colonoscopy
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Villous, nodular lesion
Open ileocecal valve
Ileal lymphoid hyperplasia
Cultures AFB,Fungus, O&P
Stains
Diseases to Consider in the
Differential Diagnosis
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Gastrointestinal
diseases
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Inflammatory bowel
disease
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Crohn’s disease
Ulcerative colitis
Nodular lymphoid
hyperplasia
Celiac disease
Necrotizing enterocolitis
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Gastrointestinal
diseases continued
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Behçet’s disease
Eosinophilic
gastroenteritis
Hirschsprung’s disease
with necrotizing
enterocolitis
Neoplasms
Anatomical or vascular
abnormalities
Diseases to Consider in the
Differential Diagnosis Continued
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Hematologic diseases
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Chronic granulomatous
disease
Langerhans’ –cell
histiocytosis
Familial hemophagocytic
lymphohistiocytosis
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Systemic inflammatory
diseases
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Sarcoidosis
Wegener’s
granulomatosis
Juvenile
dermatomyositis
Juvenile rheumatoid
arthritis
Systemic lupus
erythematosus
Diseases to Consider in the
Differential Diagnosis continued
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Infectious diseases
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Mycobacterium tuberculosis infection
M. avium infection
Yersinia infection
Giardia lamblia infection
Tropheryma whippelii infection
Bartonella henselae infection
Differential DX
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Yersinia
Sarcoidosis
Crohn’s disease
Tuberculosis
Yersinia
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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
Sarcoidosis
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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
Tuberculosis
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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
Tuberculosis organisms
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M. tuberculosis
M.bovis
(M. avium)
Patients At Higher Risk
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Immigrants (travel endemic areas)
AIDS
Urban poor
Living on reservations
Prisoners
NH residents
Gastrointestinal Areas
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Ileocecal/ileal approx 75%
Asc.colon appendix approx 20%
Uncommon jejunum,stomach,esophagus,
sigmoid/rectum, anal
Multiple areas-skip areas
Clinical Sx and Exam
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Non-specific sx 80-90%
pain
wt loss
diarrhea/constipation
blood in stools
PE abdominal mass
perianal lesions
Complications
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Hemorrhage
Perforation
Obstruction
Fistula formation
Malabsorption
Endoscopic Findings
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Ulcerative
60%
Hypertrophic 10%
Mixed
30%
Circumferential ulcers
Scarred open IC valve
Radiological Findings
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BE/SBFT ulcers
thickening/distortion
stenosis
pseudopolyps
CT
adenopathy-central necrosis
mass
calcified nodes
Diagnosis
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Stain
PCR
Culture
<20%
80%
<30% mucosal biopsies
? % surgical specimen esp node
n.g. stool esp with pulm disease
Presumptive +PPD, +CXR
Therapeutic Response
Clinical Course
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Iron RX increase hgb felt less dizzy
+ AFB culture
M.gordonia
Ten Diseases Doctors Miss
Reader’s Digest Feb 2003
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Hepatits C
Lupus
Celiac Disease
Hemochromatosis
Aneurysm
Lyme Disease
Hypothyroidism
Polycystic Ovary Syndrome
Chlamydia
Sleep Apnea