Mimics of Crohn`s disease

Intro …. Diagnosis of Crohn`s disease Diagnosis of Crohn`s disease Clinical presentation Clinical presentation Relevant lab findings Relevant lab findings Supportive radiology Supportive radiology Supportive endoscopy Supportive endoscopy Supportive histology Supportive histology Radiological Mimics Radiological Mimics Endoscopic Mimics Endoscopic Mimics Histological Mimics Histological Mimics

Today …. Radiological Mimics Radiological Mimics Endoscopic Mimics Endoscopic Mimics Histological Mimics Histological Mimics

Case 1 …. 36 yr old male 36 yr old male 3 months history 3 months history Abdominal pain Abdominal pain Diarrhoea – no blood or mucous Diarrhoea – no blood or mucous Weight loss 12 pounds in 2 months Weight loss 12 pounds in 2 months PMH/FH- nil relevant PMH/FH- nil relevant Pallor +, No nodes Pallor +, No nodes Abdo exam : Abdo exam : Tender RIF Tender RIF `Fullness ` RIF `Fullness ` RIF No mass No mass Bowel sounds normal Bowel sounds normal PR - NAD PR - NAD Hb 11.9, MCV 81 WCC 11.2, Neutrophils 7.9 Platelets 549, CRP 17 Hb 11.9, MCV 81 WCC 11.2, Neutrophils 7.9 Platelets 549, CRP 17 LFT – Normal except alb 31 LFT – Normal except alb 31

Radiology …. Abdo X ray – Normal Abdo X ray – Normal Ultrasound -NAD Ultrasound -NAD CT abdomen - ` Mass ileo-caecal area with thickening of distal ileum and caecum. Some fluid and air around the bowel loops and small mesenteric nodes. Appearances suggestive of inflammatory bowel disease of Crohns type `. CT abdomen - ` Mass ileo-caecal area with thickening of distal ileum and caecum. Some fluid and air around the bowel loops and small mesenteric nodes. Appearances suggestive of inflammatory bowel disease of Crohns type `.

Radiology …. Small Bowel enema- `Ulcerated narrowed terminal ileum. The contrast fills the caecum which appear deformed. The appearances suggestive of ileocaecal Crohn`s disease. No obstruction`. Small Bowel enema- `Ulcerated narrowed terminal ileum. The contrast fills the caecum which appear deformed. The appearances suggestive of ileocaecal Crohn`s disease. No obstruction`.

Treatment …. IV antibiotics- Cipro and Flagyl for 4 days IV antibiotics- Cipro and Flagyl for 4 days Surgical review Surgical review Imp : Crohns disease, `no acute surgical problem` Imp : Crohns disease, `no acute surgical problem` Refer to gastroenterologist Refer to gastroenterologist IV hydrocortisone 100 mg QDS x 2 days IV hydrocortisone 100 mg QDS x 2 days Oral prednisoloone 30 mg daily, Pentasa 500mg TDS Oral prednisoloone 30 mg daily, Pentasa 500mg TDS Discharge after 7 days – out patient referral Discharge after 7 days – out patient referral 6 weeks later - on W/L of a gastroenterologist 6 weeks later - on W/L of a gastroenterologist GP GP Steroids now tapered and stopped Steroids now tapered and stopped Symptoms have returned – mostly pain Symptoms have returned – mostly pain After initial improvement now poor appetite and no further weight gain After initial improvement now poor appetite and no further weight gain Dose of Pentasa increased to 1gm TDSHb 11.1, PV , alb - 27 Dose of Pentasa increased to 1gm TDSHb 11.1, PV , alb - 27 ? Restart steroids ? Restart steroids

IBD clinic …. Looks unwell, Pale, Apyrexial Looks unwell, Pale, Apyrexial Abdo exam: Abdo exam: Tender mass RIF. Superficial skin `warm` Tender mass RIF. Superficial skin `warm` Bloods – Hb 10.3, MCV 79, Platelets 542, Albumin 26, Bloods – Hb 10.3, MCV 79, Platelets 542, Albumin 26, CRP 42 CRP 42 Colonoscopy- Normal to caecum, Posterior to caecal pole a punched out area of ulceration with fistulization to ileum. The ileo-caecal valve opening was identified adjacent to fistula. On entry into ileum through ileocaecal valve the last 10 cms of ileum normal Colonoscopy- Normal to caecum, Posterior to caecal pole a punched out area of ulceration with fistulization to ileum. The ileo-caecal valve opening was identified adjacent to fistula. On entry into ileum through ileocaecal valve the last 10 cms of ileum normal Biopsy : Both from the ulcer and the fistulous tract – Poorly differentiated adenocarcinoma Biopsy : Both from the ulcer and the fistulous tract – Poorly differentiated adenocarcinoma

Management …. Laparotomy Laparotomy Large tumour fistulizing into ileum about 7 cms from the ileocaecal valve Large tumour fistulizing into ileum about 7 cms from the ileocaecal valve Infiltration of psoas muscle Infiltration of psoas muscle 5/9 nodes positive 5/9 nodes positive No liver mets No liver mets Stage - T4N2M0 ( Dukes C) Stage - T4N2M0 ( Dukes C) 6 months review. No recurrence 6 months review. No recurrence

Case 2 …. 58yr old female 58yr old female Extensively investigated 3 yrs ago in Chicago- CT, colonoscopy etc- Extensively investigated 3 yrs ago in Chicago- CT, colonoscopy etc- diagnosis- IBS diagnosis- IBS 3 months h/o increasing symptoms abdominal pain, diarrhoea, bloating 3 months h/o increasing symptoms abdominal pain, diarrhoea, bloating 2 admissions with pain- 2 admissions with pain- diagnosis- constipation diagnosis- constipation 3 rd admission- increasing episodes of RIF pain 3 rd admission- increasing episodes of RIF pain Exam- diffuse abdo tenderness, distended Exam- diffuse abdo tenderness, distended Bloods – hb- 11.7, CRP 34, alb 28 Bloods – hb- 11.7, CRP 34, alb 28

Radiology …. `abnormal thick walled terminal ileum. Surrounding mesentery normal. Crohn`s disease would be primary consideration.`

Management…. Colonoscopy- `poor prep. Erythematous oedematous and deformed ileocaecal valve`. Terminal ileum ? Colonoscopy- `poor prep. Erythematous oedematous and deformed ileocaecal valve`. Terminal ileum ? Treatment: IV steroids, mesalazine Treatment: IV steroids, mesalazine Symptoms better Symptoms better Gastro review- Oral steroids. Gastro review- Oral steroids. Discharged on day 9 Discharged on day 9 Histology- non specific inflammation Histology- non specific inflammation Attended for rpt colonoscopy 6 weeks later. Feels well. Down to 10mg prednisolone/day Attended for rpt colonoscopy 6 weeks later. Feels well. Down to 10mg prednisolone/day

Colonoscopy …. Ulcerated lesion on the ileocaecal valve with fistulization into terminal ileum. Terminal ileal mucosa normal

Treatment… Biopsy- adenocarcinoma Biopsy- adenocarcinoma Surgery- T4 N1 lesion adherent to anterior abdominal wall, Dukes C Surgery- T4 N1 lesion adherent to anterior abdominal wall, Dukes C Adjuvant chemo Adjuvant chemo Under follow up Under follow up

Messages…. Consider clinical presentation, radiological and endoscopic data in combination to diagnosis Consider clinical presentation, radiological and endoscopic data in combination to diagnosis Give accurate clinical data when requesting CT Give accurate clinical data when requesting CT If necessary discuss CT with a gastro radiologist/gastroenterologist If necessary discuss CT with a gastro radiologist/gastroenterologist Watch out for radiological mimics of Ileocaecal Crohns disease Watch out for radiological mimics of Ileocaecal Crohns disease Adenocarcinoma of caecum, ileum, appendix Adenocarcinoma of caecum, ileum, appendix Lymphoma Lymphoma Inflammatory appendicular mass Inflammatory appendicular mass Caecal diverticulitis Caecal diverticulitis Ileocaecal tuberculosis Ileocaecal tuberculosis Terminal ileal intubation should be attempted in all suspected cases of Crohns Terminal ileal intubation should be attempted in all suspected cases of Crohns Will avoid pitfalls Will avoid pitfalls Confirms complete colonoscopy Confirms complete colonoscopy

CASE 3 …. 73 yr with coeliac disease diagnosed Well on GFD 73 yr with coeliac disease diagnosed Well on GFD Admission with severe iron deficiency anaemia in June 08 Admission with severe iron deficiency anaemia in June 08 No GI symptoms except some upper abdo pain. No GI symptoms except some upper abdo pain. Bloods – Hb 5.7, MCV 66, Platelets 648 Bloods – Hb 5.7, MCV 66, Platelets 648 Endoscopy- `normal to 2 nd part of duodenum` Endoscopy- `normal to 2 nd part of duodenum` CT - `there is thickening, inflammation and enhancement of D3 and D4 with peri-duodenal inflammation. Findings would be in keeping with IBD and probable Crohn`s of D3 and D4` CT - `there is thickening, inflammation and enhancement of D3 and D4 with peri-duodenal inflammation. Findings would be in keeping with IBD and probable Crohn`s of D3 and D4` Treatment- transfusion, steroids, iron supp Treatment- transfusion, steroids, iron supp Discharge with follow up with the gastroenterologist- appointment October 08 Discharge with follow up with the gastroenterologist- appointment October 08

2 months later …. Readmission with anaemia Hb 4.7 Readmission with anaemia Hb 4.7 AAU- inv CT!!! AAU- inv CT!!!

Endoscopy …. Distal duodenum grossly abnormal with nodular and ulcerated mucosa and luminal narrowing suggestive of lymphoma or adenocarcinoma

Management …. Histology – adenocarcinoma Histology – adenocarcinoma MDT, upper GI surgery review- not amenable for curative resection MDT, upper GI surgery review- not amenable for curative resection Being considered for palliative bypass + RT Being considered for palliative bypass + RT

Messages…. Standard of care for iron deficiency anaemia- Pan-endoscopy. CT useful only in very select cases. Standard of care for iron deficiency anaemia- Pan-endoscopy. CT useful only in very select cases. Well controlled celiac patient who develops anaemia- think of complications Well controlled celiac patient who develops anaemia- think of complications Isolated upper GI Crohns in elderly unknown Isolated upper GI Crohns in elderly unknown Give accurate clinical info to radiologist (again !!!) Give accurate clinical info to radiologist (again !!!)

Case 4 …. 43 yr old female 43 yr old female Admission for surgery for a neuroma Admission for surgery for a neuroma Post op on diclofenac 50mg tds Post op on diclofenac 50mg tds Day 3- acute diffuse abdominal pain, blood in stools, diarrhoea, anaemia Day 3- acute diffuse abdominal pain, blood in stools, diarrhoea, anaemia Exam- `distended tender abdomen, guarding, BS +ve `. PR- blood++ Exam- `distended tender abdomen, guarding, BS +ve `. PR- blood++ Bloods Hb 6.3, Platelets 409, CRP 21 Bloods Hb 6.3, Platelets 409, CRP 21

CT & sigmoidoscopy…. CT - `Segmental thickening of wall of the entire colon including rectum with no injection of surrounding fat. Appearances suggest a colitis involving the entire colon` CT - `Segmental thickening of wall of the entire colon including rectum with no injection of surrounding fat. Appearances suggest a colitis involving the entire colon` Sigmoidoscopy- Deep ulcerations in rectum and sigmoid consistent with Crohn`s Sigmoidoscopy- Deep ulcerations in rectum and sigmoid consistent with Crohn`s

Repeat endo and colonoscopy

Management… NSAID stopped NSAID stopped Spontaneous resolution of symptoms Spontaneous resolution of symptoms Repeat colonoscope after 3 months Repeat colonoscope after 3 months

Message…. NSAID ulcerations occurs both in upper and lower GI tract NSAID ulcerations occurs both in upper and lower GI tract If there is temporal association think of NSAID colitis If there is temporal association think of NSAID colitis Acute presentation for panenteric Crohns unknown Acute presentation for panenteric Crohns unknown

Case 5…. 84 yr old 84 yr old Known IHD, A fib Known IHD, A fib Acute abdominal pin followed by rectal bleeding Acute abdominal pin followed by rectal bleeding Exam- ` tender, guarding, rebound, blood on PR Exam- ` tender, guarding, rebound, blood on PR Bloods – Hb 9.8, WCC 14.2, CRP 76, Lactate normal Bloods – Hb 9.8, WCC 14.2, CRP 76, Lactate normal Plain Film- `dilated bowel` Plain Film- `dilated bowel` CT - CT -

CT…. Report :

Sigmoidoscopy …. Report :ulcerated oedematous sigmoid colon. Rectum normal. Endoscopic diagnosis – colitis ? Crohns Report :ulcerated oedematous sigmoid colon. Rectum normal. Endoscopic diagnosis – colitis ? Crohns

Management …. Started on oral steroids 30 mg, mesalazine Started on oral steroids 30 mg, mesalazine Referred to IBD clinic Referred to IBD clinic Seen 3 weeks after discharge Seen 3 weeks after discharge Histology- ischemic colitis Histology- ischemic colitis Complete resolution of symptoms Complete resolution of symptoms Steroids rapidly tapered and stopped, mesalazine stopped. Steroids rapidly tapered and stopped, mesalazine stopped. Review 6 months later- well, discharged. Review 6 months later- well, discharged.

Case 6… 38 yr old male in gender 38 yr old male in gender smoker smoker Acute onset abdominal pain followed by bloody diarrhoea 24 hr later, vomiting Acute onset abdominal pain followed by bloody diarrhoea 24 hr later, vomiting Examination- tachycardic, dehydrated, diffusely tender distended abdomen with sluggish bowel sounds Examination- tachycardic, dehydrated, diffusely tender distended abdomen with sluggish bowel sounds Bloods- Normal Bloods- Normal PFA- Dilated small bowel PFA- Dilated small bowel CT- `Circumferential thickening of the sigmoid and descending colon. Rest of colon normal. Consistent with a colitis affecting the areas described`. CT- `Circumferential thickening of the sigmoid and descending colon. Rest of colon normal. Consistent with a colitis affecting the areas described`.

CT and sigmoidoscopy

Management …. Started on IV steroids and mesalazine, IV fluids, Bowel rest Started on IV steroids and mesalazine, IV fluids, Bowel rest Review on Day 4 Review on Day 4 Steroids and mesalazine stopped Steroids and mesalazine stopped Discharged day 5 Discharged day 5 Info re: possible ling to oestrogen therapy Info re: possible ling to oestrogen therapy 3/12- no suggestion of stricture 3/12- no suggestion of stricture

Messages …. While acute presentation of ulcerative colitis common, acute presentation of Crohns exceptional While acute presentation of ulcerative colitis common, acute presentation of Crohns exceptional Acute onset abd pain followed by blood in stools- think of infective causes, diverticulitis, ischemic colitis etc Acute onset abd pain followed by blood in stools- think of infective causes, diverticulitis, ischemic colitis etc In the back ground of hypo perfusion states, atherosclerotic disease and older age- high probability of ischemic colitis In the back ground of hypo perfusion states, atherosclerotic disease and older age- high probability of ischemic colitis Typical radiological and endoscopic features in ischemic colitis Typical radiological and endoscopic features in ischemic colitis Vast majority recover fully with just conservative measures within 2-3 days Vast majority recover fully with just conservative measures within 2-3 days

Chronic Ischemic colitis stricture

Local data …. Retrospective audit – 64 patients- 16 (26.5%) diagnosed presentation Retrospective audit – 64 patients- 16 (26.5%) diagnosed presentation 22 patients since /3 of radiology, endoscopy, histology 22 patients since /3 of radiology, endoscopy, histology Excluded : bowel infarction, surgery, death Excluded : bowel infarction, surgery, death 9/22 labelled as Crohns; 6 treated as Crohn`s 9/22 labelled as Crohns; 6 treated as Crohn`s

Learning material…. Sebastian S, Steele C, Torregiani W, Buckley M. Adenocarcinoma mimicking ileocaecal Crohns disease: a single centre experience. Am J Gastroenterology 2003 Sebastian S, Steele C, Torregiani W, Buckley M. Adenocarcinoma mimicking ileocaecal Crohns disease: a single centre experience. Am J Gastroenterology 2003 O`Connor HJ, Sebastian S, Torreggiani W, Buckley M, O`Morain CA. Non-IBD and noninfectious colitis. Nature clin Pract Gastroenterol and Hepatol O`Connor HJ, Sebastian S, Torreggiani W, Buckley M, O`Morain CA. Non-IBD and noninfectious colitis. Nature clin Pract Gastroenterol and Hepatol