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Case 228

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Woman, 49 years, smoker, hospitalized with severe malnutrition profile, low fever, important abdominal distension and sudden change in bowel habits, going from diarrhea to stop of feces disposal for 8 days, although maintaining elimination of flatus. Six months ago, she underwent a colonoscopy, which revealed shallow ulcers with a hyperemic halo in the distal ileum. The histopathological examination showed transmural inflammation, also lymphoid aggregates in the submucosa and in the outside of the muscle layer. CT scan of the abdomen was performed, which showed the following images:

Considering the clinical history, the findings of both colonoscopy and CT, which is the presented complication and its probable cause:

a) Intestinal obstruction due to intestinal tuberculosis

25%

b) Intestinal obstruction due to incarcerated umbilical hernia

25%

c) Intestinal semi-obstruction caused by ileal Crohn's disease

25%

d) Semi-obstruction due to ulcerative colitis

25%
   

Image analysis

Image 1: Computed tomography (CT) of the abdomen in axial view, showing small bowel loops quite distended, with slightly thickened mucosa, preserved villi (blue line) and visible ascending and descending colons (green circles). The area marked in red, both the square and the circle, shows stenotic segment of ileum, thickened mucosa and considerably reduced lumen. The local is probably responsible for the semi-obstruction. It was not observed protrusion of bowel beyond the abdominal wall, to the point of thinking of hernias.

Highlights

- Crohn's disease is more prevalent in women between 20 and 40 years and affects predominantly the distal ileum and colon but can affect the entire digestive tract from mouth to the anus;

- By presenting transmural involvement may lead to fibrosis and stricture of the bowel, presenting clinically as a intestinal obstruction or semi-obstruction;

- CT is the radiologic exam of choice by allowing visualization of the entire gastrointestinal tract, as well as stenosis areas, fistulas and possible abscesses;

- The diagnosis is based on clinical data, imaging and histopathological study;

- The medical or surgical treatment will depend on the disease location, intensity of presentation, response to previous drug therapy and in the presence of complications.

References

- Brasileiro Filho G. Bogliolo patologia (8th ed). Grupo Gen - Guanabara Koogan; 2000.

  • - SCHAFER, Andrew; GOLDMAN, Lee. Goldman Cecil Medicina. 24. ed., 2014.

  • - D'IPPOLITO, Giuseppe; CALDANA, Rogério. Gastrointestinal: CBR. São Paulo: Elsevier, 2011.

  • - Costa-Silva L , Passos  MCF, Martins T.  CT enterography: a preliminary experience in the evaluation of small bowel diseases. CBR 2010. Accessed in: september, 2015. Available in: http://www.scielo.br/pdf/rb/v43n5/v43n5a08.pdf

  • - Peppercorn Mark A, Rutgeerts Paul and Grover Shilpa. Clinical manifestations, diagnosis and prognosis of Crohn's disease in adults. Uptodate. Accessed in: september, 2015.

  • - The Differences Between Ulcerative Colitis and Crohn’s Disease [Internet]. Med Precautions. 2015. Accessed in 12/05/2016. Available in: http://medprecautions.com/the-differences-between-ulcerative-colitis-and-crohns-disease/

Authors

-Anderson Luis de Resende Jr, 5th year medical student at Universidade de Minas Gerais.

E-mail: andersonlresende[at]hotmail.com

 

-Jadson Lardy Lemes, 5th year medical student at Universidade de Minas Gerais.

E-mail: jadsonllemes[at]gmail.com

 

- Jessé Gomes Barbosa, 5th year medical student at Universidade de Minas Gerais.

E-mail: jesse.jg[at]gmail.com

 

- Bárbara de Queiroz e Bragaglia, 6th year medical student at Universidade de Minas Gerais.

E-mail: barbara.bragaglia[at]gmail.com

Supervisors

Reginaldo Figueiredo MD. Adjunct Professor and Doctor, Head of the Department of Anatomy and Image at Medical School of Universidade Federal de Minas Gerais.

E-mail figueiredoufmg[at]gmail.com

Reviewers

Giovanna Vieira, Laio Bastos, Cairo Mendes, Carla Faraco, Daniela Braga and prof. Viviane Parisotto.

Translated by

Giovanna Vieira Moreira, 4th year medical student at Universidade Federal de Minas Gerais.

E-mail: giovieiramoreira[at]gmail.com

Test question

a)

25%

b)

25%

c)

25%

d)

25%

e)

25%
   

Commentics

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