case presntation-1dr.wagdy mikhail
TRANSCRIPT
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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.
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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.
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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
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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.
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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.
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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.
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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.
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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.
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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.
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Patient developed discharging FISTULA
Colonoscopy
15- 5- 1999
7 10 - 2000
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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
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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
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What to do ????
What We did ???????????
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!!!We Started another course of INFLIXIMAB!
The FISTULA closed 2 weeks after
the 1st. Injection
Then what ????
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