Morning meeting:Morning meeting:Morning meeting:Morning meeting:

Presenter: PGY Presenter: PGY 胡子仁胡子仁Supervisor: Supervisor: 葉子洪醫師葉子洪醫師

Basic data:Name: 黃 X 民Sex: maleAge:24 y/oMarital status: unmarriedOccupation: militaryChart no:10423311Date of admission: 2010/04/27

Brief history: He suffered from dyspepsia two weeks ago, and pr

ogressed to epigastralgia recent three days. But, he denied fever, chills, nausea/vomiting, head

ache/dizziness, hematemesis/hematochezia/ melena, etc.

He also had experienced of hemoptysis and dyspnea, cough with greenish sputum one month ago.

Brief history:

Thus, he was attended our ER for help. Physical examination presented normal active bowel sound. Laboratory data showed monocytosis, CRP elevated. KUB found bowel loop dilatation. Abdomen CT discovered separate segments of wall edema and luminal stenosis of the small bowel. Thus he was admitted for further investigation.

picture

Past history and personal history:

DM and HTN: deniedSmoking: deniedAlcoholic drinking: denied Allergy: deniedTravel history at recent six

months: denied.

Physical examination: Vital sign:T= 36.5 C； P= 109beats/min； R=

17 times/min. BP=118/73mmHg. General appearance: acutely ill-looking. Sclera: no icteric. Skin: no icteric . Chest : Inspection : normal quality of expansion,

symmetrically,no respiratory accessory muscle use.

Palpation : measured expansion. Percussion : resonance, normal decent of

diaphragms. Auscultation: clearly breath sounds.

Physical examination: Abdomen: Inspection : soft, no abdominal distention, no fla

nk bulging, no operation scar, no striae, no superficial collateral vein, no umbilical hernia.

Ausculation: normal active bowel sounds, no bruit, no friction rub.

Percussion :tympanic, no shifting dullness, liver span: 7-9 cm over right mid-clavicular line.

Palpation : soft, epigastric tender pain, no Murphy's sign, no hepatomegaly, no splenomegaly, no palpable masses, no knocking pain.

Extremities= no pitting edema, no acrocyanosis.

back

CXR finding:

Laboratory data:

Diagnosis:• Segmental bowel wall edema? Crohn

’s disease or tuberculosis or others?

Computed tomography (CT), tissue characterization, 74.12112, 75.12112 ● Intestines, CT, 74.12112, 75.12112. RadioGraphics 2002; 22:109.Algorithmic approach to CT diagnosis of the abnormal bowel wall .

Discussion:IBDIntroduction: Inflammatory bowel disease (IBD) is comprised of

two major disorders: ulcerative colitis (UC) and Crohn's disease (CD). UC affects the colon, whereas CD can involve any component of the gastrointestinal tract from the oral cavity to the anus.

The peak incidence of IBD occurs in patients between the ages of 15 and 25 years. Approximately 25 to 30 percent of patients with CD and 20 percent of patients with UC present before the age of 20 years.

Workup: We suggest upper GI series with small bowel follo

w-through as the primary imaging technique to assess for small bowel disease in a patient with suspected IBD.

This test may not be necessary if another imaging modality (such as CT, MRI, or video-capsule endoscopy) has already provided an adequate examination of the small bowel. No imaging modality is a substitute for thorough endoscopic examination and histopathologic diagnosis.

Workup: If possible, the disease should be classified as eith

er CD or UC . If the disease type remains uncertain after complete evaluation, the term "indeterminate" colitis is used.

Newer classifications schemes suggest using the term "colonic IBD, type unclassified", reserving "indeterminate colitis" for patients in whom the type of IBD remains uncertain after colectomy and pathological evaluation .

Workup: Features of CD — Features strongly suggestive of C

D include frank mucosal ulceration, narrowing or obstruction, or enteric fistula. Other findings include cobblestoning, cecal narrowing, bowel rigidity, and bowel wall edema manifested by separation of bowel loops ).

The colonoscopic findings suggestive of CD include small ulcers (aphthous lesions) in the colon, discontinuous colitis with intervening areas of normal mucosa ("skip areas"), a relative decrease in the severity of inflammation in the rectum ("rectal sparing"), and granulomas identified on biopsy .

Workup: MRI and CT — Other imaging modalities,

including computerized axial tomography (CT), magnetic resonance imaging (MRI), and nuclear medicine studies are sometimes valuable in assessing for complications of IBD, but their role in the initial evaluation of a patient and the differentiation between CD and UC has not been established .

Like barium contrast studies, MRI can detect small bowel disease in areas of the small intestine that are inaccessible to endoscopy.

Workup: Certain serum antibodies may be helpful for scree

ning for IBD and discriminating UC from CD . ASCA and P-ANCA — Anti-Saccharomyces cerevisi

ae (ASCA) antibodies are found in 40 to 80 percent of individuals with CD, tend to identify patients with disease of the terminal ileum and cecum, and are unusual in patients with UC. Thus, a positive ASCA test in a patient with IBD suggests the diagnosis of CD. The sensitivity and specificity of P-ANCA and ASCA tests are similar in adults and children with IBD.

Workup: Atypical perinuclear antineutrophil cytopla

smic antibodies (atypical P-ANCA, ie, not directed against myeloperoxidase) can be detected in 60 to 80 percent of children and adults with ulcerative colitis compared to 10 to 27 percent of adults with CD (in whom only low titers may be present).

Workup: Anti OmpC antibodies — The anti-OmpC antibody

has been identified as a potential serologic marker of IBD. The OmpC is an outer membrane porin, E. coli protein that is immunoreactive to P-ANCA monoclonal antibodies .

Anti CBir1 — Antibodies to the bacterial flagellin CBir1 are found in approximately 50 percent of individuals with CD, and have been associated with small bowel, internal-penetrating and fibrostenosing patterns.

Treatment:Acute attacks: Severe disease should be referred to a specialis

t for intravenous corticosteroid treatment and consideration of total parenteral nutrition and antibiotic therapy.

Mild-to-moderate disease requires oral corticosteroid (prednisone) treatment with or without an oral aminosalicylate(5-ASA). Oral budesonide has also been found to be effective in mild-to-moderate Crohn's disease, with equal improvement rates for budesonide and prednisone.

Treatment: Mild disease is treated with an oral aminosalicyl

ate. Metronidazole is an appropriate alternative. Infliximab has been used for moderate-to-sever

e Crohn's disease that is unresponsive to corticosteroid management and to aid healing of perianal fistulas.

Tacrolimus has been used in refractory corticosteroid-dependent cases.

Adalimumab and natalizumab are approved for the treatment of moderate-to-severe disease.

Treatment: Maintenance therapy: Mesalamine(5-aminosalicycle, 5-ASA) is generally the pref

erred maintenance therapy because it is associated with fewer adverse effects than corticosteroids. Mesalamine enema may be used in disease that is limited to the rectosigmoid region.

Corticosteroids (prednisone and budesonide) should not be considered as maintenance therapy because long-term adverse effects are problematic. Corticosteroid enema use should be limited to disease of the rectosigmoid region; systemic absorption may be significant, and mesalamine is generally preferred.

Treatment: Mercaptopurine and azathioprine are excellent

alternatives where mesalamine has failed. Methotrexate may be used in selected patients

with refractory, corticosteroid-dependent Crohn's disease.

Symptomatic treatment: Endoscopic stricturoplasty - colonic strictures s

econdary to chronic scarring from Crohn's disease can occasionally be dilated with symptomatic relief.

The end!The end!The end!The end!

Thanks for your attention?Thanks for your attention?