Granulomatosis Colitis

Presented by

Dr. Leon Wolf

History

C.C. Anemia and HO + 45 yo male asymptomatic PMH h/o goiter, Rx Synthroid FH CAD DM Colonic polyps SH born outside of USA, postal worker ROS w/o wt loss, fever

w/o cough, sputum hemoptysis

Physical Exam

Healthy appearing wt.220 T.98.6 HEENT R. neck fullness Lungs clear Abd soft w/o masses, LSKK Rectal w/o masses, HO+ Ext w/o joint fullness or tenderness Skin w/o rashes

LAB

Hgb 10.6, MCV 77 WBC 8,900 ; normal differential CMP normal CEA 1.4

ENDOSCOPIC EVALUATION

Colon cecal villous,nodular friable lesion EGD gastric erythema

esophageal nodule Microscopic Colon: granulomatous colitis

Stomach: mild gastritis

Esophagus: papilloma

Clinical Course

RX Pentasa, iron CXR negative SBFT negative CTABD/PELVIS negative PPD positive 20yrs ago

Re-Colonoscopy

Villous, nodular lesion Open ileocecal valve Ileal lymphoid hyperplasia Cultures AFB,Fungus, O&P Stains

Diseases to Consider in the Differential Diagnosis

Gastrointestinal diseases

– Inflammatory bowel disease

Crohn’s disease Ulcerative colitis

– Nodular lymphoid hyperplasia

– Celiac disease– Necrotizing enterocolitis

Gastrointestinal diseases continued

– Behçet’s disease– Eosinophilic

gastroenteritis– Hirschsprung’s disease

with necrotizing enterocolitis

– Neoplasms– Anatomical or vascular

abnormalities

Diseases to Consider in the Differential Diagnosis Continued

Hematologic diseases– Chronic granulomatous

disease– Langerhans’ –cell

histiocytosis– Familial hemophagocytic

lymphohistiocytosis

Systemic inflammatory diseases

– Sarcoidosis– Wegener’s

granulomatosis– Juvenile

dermatomyositis– Juvenile rheumatoid

arthritis– Systemic lupus

erythematosus

Diseases to Consider in the Differential Diagnosis continued

Infectious diseases– Mycobacterium tuberculosis infection– M. avium infection– Yersinia infection– Giardia lamblia infection– Tropheryma whippelii infection– Bartonella henselae infection

Differential DX

Yersinia Sarcoidosis Crohn’s disease Tuberculosis

Yersinia

Gram negative rod Contaminated milk, milk products Acute manifestations Enterocolits most common <5 yo Adenitis, ileitis >5 yo Bacteremia in pts underlying disease Reiter’s syndrome Self limited 3 to 4 wks

Sarcoidosis

Gastrointestinal involvement uncommon other than liver granulomatosis

Stomach primarily,bleeding ulcerations Small intestine nodal or lymphatic blockage Esophageal obstruction lymph nodes or

infiltration Pulmonary or renal involvement with above

Tuberculosis

Koch 1882 ID bacillus Primary pulmonary disease Pre antiboitics 55-90% GI involvement Proportional to pulmonary disease Post antiboitics GI disease have <50%

pulmonary tb evidence

Tuberculosis organisms

M. tuberculosis M.bovis (M. avium)

Patients At Higher Risk

Immigrants (travel endemic areas) AIDS Urban poor Living on reservations Prisoners NH residents

Gastrointestinal Areas

Ileocecal/ileal approx 75% Asc.colon appendix approx 20% Uncommon jejunum,stomach,esophagus,

sigmoid/rectum, anal Multiple areas-skip areas

Clinical Sx and Exam

Non-specific sx 80-90%

pain

wt loss

diarrhea/constipation

blood in stools PE abdominal mass

perianal lesions

Complications

Hemorrhage Perforation Obstruction Fistula formation Malabsorption

Endoscopic Findings

Ulcerative 60% Hypertrophic 10% Mixed 30% Circumferential ulcers Scarred open IC valve

Radiological Findings

BE/SBFT ulcers

thickening/distortion

stenosis

pseudopolyps CT adenopathy-central necrosis

mass

calcified nodes

Diagnosis

Stain <20% PCR 80% Culture <30% mucosal biopsies

? % surgical specimen esp node

n.g. stool esp with pulm disease

Presumptive +PPD, +CXR Therapeutic Response

Clinical Course

Iron RX increase hgb felt less dizzy + AFB culture M.gordonia

Ten Diseases Doctors Miss Reader’s Digest Feb 2003

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