Case Report – Crohn’s Disease

Chisa Yamada, M.D.

Case : H02- 41554
 40 years old, female
 C.C.: abdominal pain
 Clinical history: Patient who has a history of
Crohn’s disease for over 12 years admitted to the
hospital on 11/08/02 with C.C. for over 2 weeks.
CT showed right lower abdominal abscess and
small bowel study showed distal ileal narrowing
and multiple fistulae formation from ileum to
ileum and ileum to cecum. Patient got an
operation on 11/29/02.
Gross Description
 Twisted segment of ileum and cecum. Ileum
measures 51 cm and 2.5 cm, cecum measures 3.5
cm and 4 cm in length and diameter respectively.
 2 ileum to ileum fistulae and 1 ileum to cecum
fistula with polypoid mucosal projection and
bridging.
 Ileum has skip lesion with variable mucosal
thickness ranging from 0.3 cm to 0.7 cm. It also
has creeping fat, serosa to serosa adhesions and
multiple linear ulcerations.
 Mucosa on cecum is unremarkable.
Microscopic Findings
 Chronic active ileo-colitis with transmural
inflammation, fibrosis, deep linear ulcers.
 Mild cryptitis and mild architectural distortion.
 Granulomas are not identified.
Crohn’s Disease
 Incidence : 1-3 / 100,000 in the US
 Peak age : 20-40, 60-80 years old
 Sex : Female > Male
 Race : Whites : non-whites = 3-5 : 1
 Symptoms : diarrhea(rarely bleeding), fever,
abdominal pain, dyspepsia, malabsorption,
perianal diseases.
 Extraintestinal manifestation : ankylosing
spondylitis, iritis, episcleritis, sclerosing
cholangitis, erythema nodosum, clubbing of
fingers.
Crohn’s Disease
 Gross features :
aphthoid ulcers, skip lesions, cobble stoning,
rectal sparing, longitudinal “railroad track” ulcer
or transverse “bear-craw” ulcers, inflammatory
polyps, thickening of the wall, strictures, fistulas,
abscess, toxic dilatation, carcinoma(rare)
 Histological features :
Glanulomas, aphthoid ulcers, focal cryptitis, focal
chronic infiltration, disproportionate submucosal
inflammation, acute terminal ileitis, architectural
distortion.
Differential Diagnosis - Gross
Gross features Crohn’s enteritis Crohn’s colitis Ulcerative colitis
Bowel region Ileum, colon Colon, Ileum Colon (Rectum)

Distribution Skip lesions Skip lesions Diffuse

Thick bowel wall Yes Yes No

Stricture Often Sometimes No

Mucosal edema Yes Yes Usually no

Discrete mucosal ulcers Yes Yes Usually no

Creeping fat Often Often Usually no

Fistula Common Sometimes No

Serositis Yes Yes No

Inflammatory polyps Rare Sometimes Sometimes

 Differential Diagnosis - Histology
Histological features Crohn’s enteritis Crohn’s colitis Ulcerative colitis

Granulomas Common Sometimes No

Ulcers Deep, Linear Deep, Linear Superficial

Transmural inflammation Yes Yes No

Submucosal inflammation Yes Yes Usually no

Lymphoid reaction Marked Marked Mild

Fibrosis Marked Moderate Mild

Neuronal hyperplasia Yes Sometimes Usually no

Thickening of muscularis mucosae Yes, Patchy Yes, Patchy Yes, Diffuse

Architectural distortion Focal Usually focal Diffuse

 Differential Diagnosis
Features Crohn’s disease Ischemic bowel disease Tuberculosis
Discrete ulcers Yes Yes Yes
Linear ulcers Yes Yes Usually no
Stricture Yes Yes Yes
Lymphoid aggregates Yes No Usually no
Hemorrhage and necrosis No Yes No
Granulation and fibrosis No Yes Sometimes
Hemosiderin deposition Usually no Often Usually no
Preferred location Ileum, Cecum Splenic flexure Ileum, Cecum
Granulomas Often No Yes
Confluence of granulomas No Sometimes
Necrotizing granulomas No Sometimes
Fibrosis of muscularis propria Usually no Yes Yes
References
 Gastrointestinal Pathology and Its Clinical
Implications, Klaus J. Lewin, p858-903
 Diagnostic Surgical Pathology, 3rd Edition,
Stephen S. Steinberg, p1375-1383
 Pathologic Basis of Disease, Ramzi S. Cotlan,
p800-806