Case Presntation-1dr.wagdy Mikhail

8/2/2019 Case Presntation-1dr.wagdy Mikhail

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CASE PRESNTATION

Dr.Wagdy EMILE MIKHAIL

Gastroenterologist

International Modern Hospital


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1Case #

HISTORY:

Mr. MKN 34 years Indian accountant married with no children,

does not smoke or consume alcohol.

1996November

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 painDull aching deep seated pain >

during previous 2 months.

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

Low grade feverfor the previous month.

NO H/O Joint pains,skin rashes or mouth ulcers.


3/20

EXAMINATION:

BMI 18.7 wt. 51 kg ht. 165 cmThere 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.


4/20

COLONOSCOPY :

The Proximal

Ascending Colon

showed a Polypoid

mass with ulcerated

surface & causingsevere stenosis not

allowing further

intubations.The

extent of the stricturecould not be

evaluated


5/20

MICROSCOPIC EXAMINATION

Sections revealed a large bowel mucosa with acute &

chronic inflammatory infiltrate with the presence ofhaemorrhage,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.


6/20

DIFFERENTIAL DIAGNOSIS

Crohn`Disease. Intestinal TB.

Malignancy.

What is the Next Step?

Treat as Crohn`s Disease? Treat as TB?

Surgery?


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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 Mali nanc detected.


11/20

Post-operativetreatment & Follow up:

Anti-TB drugs started preoperatively & continued post-operatively ;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.


12/20

COLONOSCOPY ( 19-3-1998 )

The mucosa of the terminal ileum was congested & deeplinear 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.


13/20

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.


14/20

TREATMENT & PROGRESS

Asacol 400mg TDS Changed to PENTASA 500 mg QDS.

Maintained minimal symptoms with no Leucocytosis& ESR

20 49 .

20 10 1998

Admitted withAbd. Pain.

Fever & Abdominal wall Abscess.

Treatment :

Surgical drainageAntibiotics including Flagyl.

Pentasa 500 mg QDS.

Predisolone 60 mg Reduced gradually.


15/20

Patient developed discharging FISTULA

Colonoscopy

15- 5- 1999

7 10 - 2000


16/20

Treatment with INFLIXIMAB

Protocol:

oInfliximab 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


17/20

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.

.200133ONREOPENEDFISTULA


18/20

What to do ????

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


19/20

!!!We Started another course of INFLIXIMAB!

The FISTULA closed 2 weeks after

the 1st. Injection

Then what ????


20/20

Case Presntation-1dr.wagdy Mikhail

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