Anna Cheek, MD1, Avanija Buddam, MBBS1, Haitam Buaisha, MBBCh2 1Creighton University, Omaha, NE; 2Creighton University School of Medicine, Omaha, NE
Introduction: Crohn’s disease (CD) can mimic ischemic colitis (IC) in the elderly. Here we present an elderly male diagnosed with CD when IC was initially suspected, and further evaluation revealed that CD was the primary diagnosis.
Case Description/Methods: A 69-year-old male with a history of coronary artery disease with recent percutaneous coronary angioplasty & stent placement on aspirin and clopidogrel presented with hematochezia. He had an acute onset of a large amount of rectal bleeding and denied any other symptoms or having prior hematochezia or chronic diarrhea. Exam noted for hemodynamic stability with no tenderness to palpation of abdomen. Hemoglobin was 10.3 from 17 (Normal [N]: 13.5-17.5 gm/dl). Clinically suspected to have IC. Esophagogastroduodenoscopy (EGD) showed a small superficial non-bleeding gastric ulcer, gastritis, and duodenitis, and no stigmata of recent bleeding. Colonoscopy revealed three large deep ulcers in the proximal descending colon, splenic flexure, and distal transverse colon, with the largest ulcer measuring 50 mm. These ulcers were characterized by heaped up margins with some reactive granulation tissue, suggestive of chronicity. Biopsies showed focal acute cryptitis and diffuse lymphoplasmacytic inflammation in lamina propria without architectural distortion. CT angiography abdomen and pelvis showed widely patent arterial vasculature. Clopidogrel was held for 2 weeks to check healing of ulceration. Repeat colonoscopy showed similar findings, without improvement of ulcerations. Repeat colonic biopsies showed chronic moderately active colitis with ulceration, cytomegalovirus staining was negative. Fecal calprotectin was >3000 [N: < 49 ug/g]. C-reactive protein was 63 [N: < 9 mg/L]. MR Enterography with no small bowel disease but noted hyperenhancement and thickening in the ascending and transverse colon. The initial findings, work up and lack of resolution, was most consistent with CD.
Discussion: It is critical to distinguish IC from CD for appropriate management of patients. Differentiating between IC and CD can be challenging in the elderly. Endoscopy and histologic evaluation can aid correct diagnosis. Repeat endoscopy to assess progression or resolution is of utmost importance in differentiating CD from IC, but data is limited on appropriate timing. Lack of follow up endoscopy will most likely lead to misdiagnosis and incorrect management of the underlying pathology. Thus, a high index of suspicion must be maintained when discerning CD from IC.
Figure: Image A: Initial colonoscopy showing heaping upped margins of the splenic flexure ulcerations. Image B: Repeat colonoscopy showing deep colonic ulceration with heaped up margins at the area of splenic flexure without any resolution.
Anna Cheek indicated no relevant financial relationships.
Avanija Buddam indicated no relevant financial relationships.
Haitam Buaisha indicated no relevant financial relationships.
Anna Cheek, MD1, Avanija Buddam, MBBS1, Haitam Buaisha, MBBCh2. P1662 - Crohn’s Colitis Mimicking Ischemic Colitis: A Case Report, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.