A case of acute appendicitis preceding the diagnosis of crohn’s disease
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thickened folds, the biopsy was diagnostic of MAI as evident by the presence of macrophages and acid–fast bacilli. The second patient was 64 –year– old male with abdominal pain of five months duration. postprandial, no response to PPI. 10 pound documented weight loss, PMHx was significant for CAD, COPD, and A–Fib. PE/ Blood work were normal. A CT scan was normal, but EGD showed duodenal mucosa with a “feathery” swollen appearance, little punctuated yellowish papules. The biopsy as in the first case showed numerous foamy macrophages located in the lamina propria. With rod–shaped inclusion bodies contained in the macrophages, that stained negative for acid fast, but positive for periodic acid Schiff (PAS). Our presentation illustrate the typical pictures endoscopically and patho- logically of two distinctive diseases that can involve the duodenum, and can present a diagnostics dilemma. 435 A CASE OF ACUTE APPENDICITIS PRECEDING THE DIAGNOSIS OF CROHN’S DISEASE Amit Rastogi and Miguel Regueiro*. Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA. Introduction: Crohn’s disease (CD) may cause inflammation of the ap- pendix that is associated with ileocolonic disease or as isolated granulo- matous inflammation without surrounding ileocecal inflammation. Rarely do patients (pts) with CD develop acute suppurative appendicitis and there are only few reported cases of acute suppurative appendicitis as the sentinel presentation of CD. We report a case of a patient(pt) who developed acute suppurative appendicitis that preceded the diagnosis of CD. Case Report: A 24 year old female with no past medical history, under- went an emergent appendectomy for acute appendicitis. At the time of surgery, there was evidence of an inflamed and perforated appendix com- plicated by a pelvic abscess. The appendix was removed and the abscess was drained. Intraoperatively, there was no sign of inflammatory bowel disease (IBD). She returned one month post– operatively with right lower quadrant pain, fever, weight loss, and an elevated white blood cell count. On exam, she had a tender 5 x 5 cm mass in the right lower quadrant and a CT scan that revealed dilated loops of small bowel with an associated phlegmon and inflamed terminal ileum. An exploratory laprotomy revealed a markedly inflamed and strictured ileum with an interloop abscess. In the proximal ileum there was a separate non–inflamed 2 cm stricture. A stricturoplasty was performed on the proximal stricture and the terminal ileum and cecum were resected with a subsequent ileocolic anastomosis. The pathology confirmed a diagnosis of CD and 3 months post– operatively the pt is without symptoms. Discussion: In the original description of regional ileitis in 1932, Crohn et al stated that the disease process never transcends the Bauhin’s (ileocecal) valve and the appendix is always free from guilt and free from changes. Since then there have been reports of appendiceal involvement in patients with Ulcerative colitis and , to a lesser extent, CD. The association of acute suppurative appendicitis in a pt with CD is rare. As more is understood about the environental and immunogenetic factors in IBD there is evidence that the apppendix should no longer be viewed as a vestigeal organ and may serve as a target for inflammation in pts with IBD. In general, pts who develop inflammatory or infectious complications after appendectomy should raise the suspicion of CD and undergo further evaluation. 436 ABDOMINAL WALL SINUS: UNUSUAL PRESENTATION OF CHRONIC CHOLECYSTITIS Irena Zalewska, M.D. and Nadeem Ullah, M.D.*. Gastroenterology, John D. Dingell VA Medical Center, Detroit, MI. Purpose: We report a case of 45–year– old man admitted for delirium. During hospitalization, patient reported right upper quadrant abdominal pain which he experienced for about six months. The pain was associated with significant weight loss but not with fever or jaundice. On examination, mildly tender subcutaneous mass, 10 cm in diameter, was palpable in the right upper quadrant of the abdomen. Blood tests including white blood count, liver enzymes, alkaline phasphatase, and bilirubin were all within normal limits. Abdominal ultrasound demonstrated distended gallbladder with thickened wall containing stones and bile sludge. There was another hypoechoic area within abdominal wall containing multiple hyperechoic foci, possible stones. Computed tomography scan confirmed sonography findings of distended gall bladder and a large hypodense mass in the anterior abdominal wall. CT– guided drainage of the abdominal wall mass revealed dark brown, purulent material from which Escherichia coli was cultured. A fistulogram through the drainage catheter was performed to identify the origin of the fluid collection; however, it showed no communication with the intraperi- toneal cavity. Subsequently, patient underwent open cholecystectomy and evacuation of the remainder of the abdominal wall abscess. Ruptured gallbladder containing multiple small gallstones fistulizing to the muscular layer of the anterior abdominal wall was disclosed. In addition, multiple small stones (50) were found in the abdominal wall abscess. The histological exam- ination of the gallbladder demonstrated perforated gallbladder with mark- edly thickened wall, xanthogranulation reaction and fistulous tract forma- tion. There was no evidence of malignancy. Postoperatively, the patient continued receiving antibiotic treatment for 10 days and recovered well. S144 Abstracts AJG – Vol. 97, No. 9, Suppl., 2002
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Transcript of A case of acute appendicitis preceding the diagnosis of crohn’s disease
thickened folds, the biopsy was diagnostic of MAI as evident by thepresence of macrophages and acid–fast bacilli.
The second patient was 64–year–old male with abdominal pain of fivemonths duration. postprandial, no response to PPI. 10 pound documentedweight loss, PMHx was significant for CAD, COPD, and A–Fib.
PE/ Blood work were normal. A CT scan was normal, but EGD showedduodenal mucosa with a “feathery” swollen appearance, little punctuatedyellowish papules.
The biopsy as in the first case showed numerous foamy macrophageslocated in the lamina propria. With rod–shaped inclusion bodies containedin the macrophages, that stained negative for acid fast, but positive forperiodic acid Schiff (PAS).
Our presentation illustrate the typical pictures endoscopically and patho-logically of two distinctive diseases that can involve the duodenum, and canpresent a diagnostics dilemma.
435
A CASE OF ACUTE APPENDICITIS PRECEDING THEDIAGNOSIS OF CROHN’S DISEASEAmit Rastogi and Miguel Regueiro*. Gastroenterology, Hepatology andNutrition, University of Pittsburgh Medical Center, Pittsburgh, PA.
Introduction: Crohn’s disease (CD) may cause inflammation of the ap-pendix that is associated with ileocolonic disease or as isolated granulo-matous inflammation without surrounding ileocecal inflammation. Rarelydo patients (pts) with CD develop acute suppurative appendicitis and there
are only few reported cases of acute suppurative appendicitis as the sentinelpresentation of CD. We report a case of a patient(pt) who developed acutesuppurative appendicitis that preceded the diagnosis of CD.Case Report: A 24 year old female with no past medical history, under-went an emergent appendectomy for acute appendicitis. At the time ofsurgery, there was evidence of an inflamed and perforated appendix com-plicated by a pelvic abscess. The appendix was removed and the abscesswas drained. Intraoperatively, there was no sign of inflammatory boweldisease (IBD). She returned one month post–operatively with right lowerquadrant pain, fever, weight loss, and an elevated white blood cell count.On exam, she had a tender 5 x 5 cm mass in the right lower quadrant anda CT scan that revealed dilated loops of small bowel with an associatedphlegmon and inflamed terminal ileum. An exploratory laprotomy revealeda markedly inflamed and strictured ileum with an interloop abscess. In theproximal ileum there was a separate non–inflamed 2 cm stricture. Astricturoplasty was performed on the proximal stricture and the terminalileum and cecum were resected with a subsequent ileocolic anastomosis.The pathology confirmed a diagnosis of CD and 3 months post–operativelythe pt is without symptoms.Discussion: In the original description of regional ileitis in 1932, Crohn etal stated that the disease process never transcends the Bauhin’s (ileocecal)valve and the appendix is always free from guilt and free from changes.Since then there have been reports of appendiceal involvement in patientswith Ulcerative colitis and , to a lesser extent, CD. The association of acutesuppurative appendicitis in a pt with CD is rare. As more is understoodabout the environental and immunogenetic factors in IBD there is evidencethat the apppendix should no longer be viewed as a vestigeal organ and mayserve as a target for inflammation in pts with IBD. In general, pts whodevelop inflammatory or infectious complications after appendectomyshould raise the suspicion of CD and undergo further evaluation.
436
ABDOMINAL WALL SINUS: UNUSUAL PRESENTATION OFCHRONIC CHOLECYSTITISIrena Zalewska, M.D. and Nadeem Ullah, M.D.*. Gastroenterology,John D. Dingell VA Medical Center, Detroit, MI.
Purpose: We report a case of 45–year–old man admitted for delirium.During hospitalization, patient reported right upper quadrant abdominalpain which he experienced for about six months. The pain was associatedwith significant weight loss but not with fever or jaundice. On examination,mildly tender subcutaneous mass, 10 cm in diameter, was palpable in theright upper quadrant of the abdomen. Blood tests including white bloodcount, liver enzymes, alkaline phasphatase, and bilirubin were all withinnormal limits. Abdominal ultrasound demonstrated distended gallbladderwith thickened wall containing stones and bile sludge. There was anotherhypoechoic area within abdominal wall containing multiple hyperechoicfoci, possible stones. Computed tomography scan confirmed sonographyfindings of distended gall bladder and a large hypodense mass in theanterior abdominal wall.
CT–guided drainage of the abdominal wall mass revealed dark brown,purulent material from which Escherichia coli was cultured. A fistulogramthrough the drainage catheter was performed to identify the origin of thefluid collection; however, it showed no communication with the intraperi-toneal cavity.
Subsequently, patient underwent open cholecystectomy and evacuationof the remainder of the abdominal wall abscess. Ruptured gallbladdercontaining multiple small gallstones fistulizing to the muscular layer of theanterior abdominal wall was disclosed. In addition, multiple small stones(�50) were found in the abdominal wall abscess. The histological exam-ination of the gallbladder demonstrated perforated gallbladder with mark-edly thickened wall, xanthogranulation reaction and fistulous tract forma-tion. There was no evidence of malignancy. Postoperatively, the patientcontinued receiving antibiotic treatment for 10 days and recovered well.
S144 Abstracts AJG – Vol. 97, No. 9, Suppl., 2002
