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Editor’s quiz: GI snapshot Robin Spiller, editor
In disguise as an acute flare: an unusual differential diagnosis of Crohn’s disease CLINICAL PRESENTATION This 33-year-old man presented to our outpatient clinic with acute watery diarrhoea and abdominal cramps of 3 days duration suggesting an acute flare of Crohn’s disease. The disease had been diagnosed 3 years previously with terminal ileitis and was treated with temporary prednisolone and azathioprine 2.5 mg/kg body weight. So far, no abdominal operations had been performed. Clinical examination was inconspicuous except for a discrete abdominal pain on deep palpation in all four quadrants. Inflammatory markers were elevated (C-reactive protein = 57.8 mg/l; normal range: ,5.0; leucocytes = 20.286109/litre; 3.80–9.80). Stool examination was negative for pathogens. Imaging demonstrated a thickening (5 mm) of the terminal ileum and mesenterial lymphadenopathy (fig 1), but ileo-colonoscopy did not reveal any signs of acute activity of Crohn’s disease. In oesophago-gastro-duodenoscopy an erythema of the gastric and duodenal mucosa was seen, specimens being taken for histopathological investigation (figs 2 and 3).
Figure 2 Histopathological findings in the gastric mucosa (haematoxylin & eosin; 6400).
QUESTION What is the diagnosis? See page 832 for the answer
Figure 3 Histopathological findings in the duodenum (haematoxylin & eosin; 61000). This case is submitted by:
J G Albert,1,2 F S Gittinger,2 M Hainz,3 C Lu¨bbert2 1 Department of Medicine I, J.-W.-Goethe University Frankfurt, Germany; 2 First Department of Medicine, Martin-Luther-University, Halle (Saale), Germany; 3 Department of Pathology, Martin-Luther-University, Halle (Saale), Germany
Correspondence to: Dr J G Albert, Department of Medicine I, J-W-Goethe University Frankfurt, D-60590 Frankfurt/Main, Germany;
[email protected]
Figure 1 Multiple enlarged mesenteric lymph nodes were detected in the region of the superior mesenteric artery and aorta, and increased bowel wall thickness of the ileum was shown by computed tomography. An abscess or inter-enteric fistulae were not present.
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Competing interests: None. Patient consent: Obtained. Gut 2009;58:742. doi:10.1136/gut.2008.167874
Gut June 2009 Vol 58 No 6
Downloaded from gut.bmj.com on May 6, 2013 - Published by group.bmj.com
In disguise as an acute flare: an unusual differential diagnosis of Crohn's disease J G Albert, F S Gittinger, M Hainz, et al. Gut 2009 58: 742
doi: 10.1136/gut.2008.167874
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