Granulomatosis Colitis Presented by Dr. Leon Wolf

History 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 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 Hgb 10.6, MCV 77 WBC 8,900 ; normal differential CMP normal CEA 1.4

ENDOSCOPIC EVALUATION Colon cecal villous,nodular friable lesion EGD gastric erythema esophageal nodule Microscopic Colon: granulomatous colitis Stomach: mild gastritis Esophagus: papilloma

Clinical Course RX Pentasa, iron CXR negative SBFT negative CTABD/PELVIS negative PPD positive 20yrs ago

Re-Colonoscopy Villous, nodular lesion Open ileocecal valve Ileal lymphoid hyperplasia Cultures AFB,Fungus, O&P Stains

Diseases to Consider in the Differential Diagnosis Gastrointestinal diseases – Inflammatory bowel disease Crohn’s disease Ulcerative colitis – Nodular lymphoid hyperplasia – Celiac disease – Necrotizing enterocolitis Gastrointestinal diseases continued – Behçet’s disease – Eosinophilic gastroenteritis – Hirschsprung’s disease with necrotizing enterocolitis – Neoplasms – Anatomical or vascular abnormalities

Diseases to Consider in the Differential Diagnosis Continued Hematologic diseases – Chronic granulomatous disease – Langerhans’ –cell histiocytosis – Familial hemophagocytic lymphohistiocytosis Systemic inflammatory diseases – Sarcoidosis – Wegener’s granulomatosis – Juvenile dermatomyositis – Juvenile rheumatoid arthritis – Systemic lupus erythematosus

Diseases to Consider in the Differential Diagnosis continued Infectious diseases – Mycobacterium tuberculosis infection – M. avium infection – Yersinia infection – Giardia lamblia infection – Tropheryma whippelii infection – Bartonella henselae infection

Differential DX Yersinia Sarcoidosis Crohn’s disease Tuberculosis

Yersinia 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 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 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 M. tuberculosis M.bovis (M. avium)

Patients At Higher Risk Immigrants (travel endemic areas) AIDS Urban poor Living on reservations Prisoners NH residents

Gastrointestinal Areas Ileocecal/ileal approx 75% Asc.colon appendix approx 20% Uncommon jejunum,stomach,esophagus, sigmoid/rectum, anal Multiple areas-skip areas

Clinical Sx and Exam Non-specific sx 80-90% pain wt loss diarrhea/constipation blood in stools PE abdominal mass perianal lesions

Complications Hemorrhage Perforation Obstruction Fistula formation Malabsorption

Endoscopic Findings Ulcerative 60% Hypertrophic 10% Mixed 30% Circumferential ulcers Scarred open IC valve

Radiological Findings BE/SBFT ulcers thickening/distortion stenosis pseudopolyps CT adenopathy-central necrosis mass calcified nodes

Diagnosis Stain <20% PCR 80% Culture <30% mucosal biopsies ? % surgical specimen esp node n.g. stool esp with pulm disease Presumptive +PPD, +CXR Therapeutic Response

Clinical Course Iron RX increase hgb felt less dizzy + AFB culture M.gordonia

Ten Diseases Doctors Miss Reader’s Digest Feb Hepatits C 2. Lupus 3. Celiac Disease 4. Hemochromatosis 5. Aneurysm 6. Lyme Disease 7. Hypothyroidism 8. Polycystic Ovary Syndrome 9. Chlamydia 10. Sleep Apnea