Transcript Crohn`s Disease: fistula

A Case of Crohn’s Disease
May/June 2013
Rich Rames, M3
Dr. Joy Sclamberg, Dr. James Cameron, Dr. Aditi Gulabani
Clinical History
• CC: RLQ abdominal pain, constipation, nausea
• HPI: 24 y/o male presents to the ED with 4-6
week h/o progressive vague abd pain with 2
weeks of constipation and watery stool with
regular laxative use.
• PMH: Pyloric stenosis (2-3 months old)
• PSH: Pyloroplasty
• Pertinent negatives: vomiting, dysuria, blood
in stool, no recent travel, weight loss
• Pertinent positives: fever, chills, fatigue
2
Clinical History
• Focused PE:
– Abd:
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•
•
•
•
Horizontal scar noted over RUQ
Soft, non-tender, not distended
Bowel Sounds-positive
Pain to deep palpation of RLQ
No rebound or guarding
• Notable Labs:
– C-Reactive Protein: 181.6
– WBC: 11.68
DDx
• Inflammatory Bowel Disease
• Bowel obstruction
• Chronic appendicitis
• Plan
– UA- negative
– Abdominal X-ray (obstruction?)
– CT Pelvis/Abd with contrast (IBD, Chronic
appendicitis?)
– Colonoscopy
What are we looking for on CT?
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•
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Bowel wall thickening
Mesenteric inflammation (“fat stranding”)
Lymph node size and number
Extra-luminal collections
– Fistulae, abscesses, sinuses
Pelvic Region
Diffuse Wall Thickening
of Segment of
Terminal Ileum
MRN: 6561716
Accession: 5273942
Post-contrast Pelvic/Abdominal CT Axial
Pelvic Region
Normal Small Bowel
MRN: 6561716
Accession: 5273942
Post-contrast Pelvic/Abdominal CT Axial
Pelvic Region
Enterocolic Fistula
MRN: 6561716
Accession: 5273942
Post-contrast Pelvic/Abdominal CT Axial
Pelvic Region
Adjacent Inflammatory
Fat Stranding
MRN: 6561716
Accession: 5273942
Post-contrast Pelvic/Abdominal CT Axial
Abdomen-Pelvis
MRN: 6561716
Accession: 5273942
Post-contrast Pelvic/Abdominal CT Coronal
Appropriateness Criteria
11
CT vs. MR Enterography- Crohn’s
• CT
– Radiation concerns
– GI wall thickening
– Extraluminal
manifestations (e.g.
abscesses)
– Quick- minutes, often
used in ED settings
– Contrast allows
differentiation of lumen
and gut wall, no fistula
visualization without it
• MR
– Avoids radiation risks,
allows for serial f/u
– GI wall thickening
– Slow (45 min-1
hr)images not as sharp
with patient moving and
normal gut peristalsis
– Difficult to pick up
subtle findings
– Improving with antiperstaltic agents and
ultrafast scans
CT vs. MR Enterography- Crohn’s
CT
MR- T2 Weighted
http://www.mghradrounds.org/index.php?src=gendocs&link=2009_september
MR Enterography
T2 Weighted, Coronal MR Abdomen
http://www.radiology.ucsf.edu/patient-care/sections/pediatric/advanced-techniques/imaging2
Crohn’s Disease
• Inflammatory Bowel Disease
• Transmural inflammation of lining of digestive
tract
• Common Signs and Symptoms
– Diarrhea
– Abdominal Pain and Cramping
– Blood in stool
– Ulcers
– Decreased appetite and weight loss
Crohn’s Disease
• Complications
– Bowel Obstruction
– Ulcers
– Fistulas
– Anal Fissure
– Malnutrition
– Colon Cancer
Follow Up
• Following CT- patient admitted
• Colonscopy
– Ileocecal valve: severe ulceration, granularity and
erythema with deformation of the valve
– Single ulcer in sigmoid colon, polyp
• Discharged after with appropriate medicationrepeat labs in 2 weeks
References
• learningradiology.com/notes/ginotes/crohnsdis
easepage.htm
• www.mayoclinic.com/health/crohnsdisease/DS00104
• http://emedicine.medscape.com/article/367666
-overview
• http://www.mghradrounds.org/index.php?src=
gendocs&link=2009_september
• Questions?