CASE PRESNTATION

Dr.Wagdy EMILE MIKHAIL Gastroenterologist International Modern Hospital

Case # 1
HISTORY: Mr. MKN 34 years Indian accountant married with no children, does not smoke or consume alcohol. November 1996 First seen in our GI Clinic C/O 1- year h/o:

Loose motions 2-3 times /day ,mixed with mucus & blood.
Rt. Lumbar region pain Dull aching deep seated pain > during previous 2 months.

Loss of weight & loss of appetite..lost ~ 20 kg. Over 1 year.

Low grade fever for the previous month. NO H/O Joint pains,skin rashes or mouth ulcers.

EXAMINATION: BMI 18.7 wt. 51 kg ht. 165 cm There was an abdominal mass felt at the Rt. Iliac fossa extending to the Rt. Lumbar region ,slightly tender. Other systemic examination was unremarkable. INVESTIGATIONS: Hb. 10.2g/dl,HCT 37 WBC.12.3x109/L, ESR 100 mm/hr.CRP 34 All other blood tests were Normal. ABD.US & CT SCAN : Extensive thickening of the Ascending with narrowed lumen & NO Para-aortic lymphadenapathy or free fluid in the peritoneum.

COLONOSCOPY :

The Proximal Ascending Colon showed a Polypoid mass with ulcerated surface & causing severe stenosis not allowing further intubations.The extent of the stricture could not be evaluated

MICROSCOPIC EXAMINATION Sections revealed a large bowel mucosa with acute &
chronic inflammatory infiltrate with the presence of haemorrhage,purulent exudative ,oedema & cryptitis. The glandular epithelial lining shows marked regenerative changes with dilated glands & mucoid material deposition.

A few glands show mildly atypical cells but NO evident malignant changes seen.
Auramine stain for AFB was Negative.

Comment: This picture is suggestive of Active Colitis ?CROHN`S DISEASE ; however other causes should be considered, eg TB or Malignancy.

DIFFERENTIAL DIAGNOSIS
Crohn`Disease. Intestinal TB. Malignancy. What is the Next Step? Treat as Crohn`s Disease?

Treat as TB?
Surgery?

Management in India:
Rt. Hemicolectomy Terminal Ileum,Caecum & Part of the Ascending Colon were resected.
MICROSCOPY : Sections of the caecum & ascending colon show erosion of the mucosa over wide areas with replacement by granulation tissue covered by pus.

The walls are markedly thickened due to fibrosis & show an intense acute & chronic inflammatory cell infiltration & few lymphoid follicles. The pericolic L.N. show non-specific reactive hyperplasia of the lymphoid tissue.
The appendix shows appearance of mucocele.

NO evidence of TB or Malignancy detected.

Post-operative treatment & Follow up: Anti-TB drugs started preoperatively & continued postoperatively ;4-drugs for 2 months & then 2 drugs for total of 10 months & supplement of Vit.B12 1 mega ut./month . After initial improvement ..developed : * Abd.pain & * Mass at Rt. Iliac fossa.. Small intestinal Enema : There is localized Ulceration & diverticuli formation at the distal terminal ileum .No other skip lesions were detected . Picture of Intestinal TB.

COLONOSCOPY ( 19-3-1998 )
The mucosa of the terminal ileum was congested & deep linear ulcerations were also present.

Multiple ulcerated polypoid masses seen largest 10 mm ,giving cobblestone appearance.

The anastomotic site was oedematous with few ulcers Picture suggestive of CROHN`N DISEASE.

Biopsy Report:
Marked acute & chronic inflammatory cell infiltrate composed mainly of lymphocytes , neutrophils , plasma cells & eosinophils. Few fragments showed ulceration & formation of granulation tissue. Few emulative purulent material seen. NO typical or definite granulomas were seen. Picture was highly suggestive of Active Ileitis, most probably CROHN`S DISEASE. AFB culture from the lesions showed NO growth after 4 weeks incubation.

TREATMENT & PROGRESS

Asacol 400mg TDS Changed to PENTASA 500 mg QDS. Maintained minimal symptoms with no Leucocytosis& ESR 20 49 .

20 10 1998 Admitted with

Abd. Pain. Fever & Abdominal wall Abscess.
Treatment : Surgical drainage Antibiotics including Flagyl. Pentasa 500 mg QDS. Predisolone 60 mg Reduced gradually.

Patient developed discharging FISTULA

Colonoscopy 15- 5- 1999

7 10 - 2000

Treatment with INFLIXIMAB

Protocol: o Infliximab 300 mg in 250 ml n/saline IV infusion over 2 3 hours at 0 , 2 & 6 weeks. (start.on 8/10/00) o Continue regular treatment *Prednisolone 5 mg OD *Pentasa 500 mg TDS.

FISTULA COMLETELY CLOSED AFTER 5WEEKS

Follow up:
Aymptomatic, fistula completely closed proved by
colonoscopy .

Azathioprine was added 75 mg OD .Inreased gradually to 2.5 mg/kg/day

Reduce Prednisolone gradually & stop after 12 weeks.

FISTULA REOPENED ON 3 3 2001.

What to do ????

What We did ???????????

We Started another course of INFLIXIMAB!!!!

The FISTULA closed 2 weeks after the 1st. Injection Then what ????