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Case 10: Abdominal pain and bloating

A 32 year old man with Crohn's disease presented with several months of progressive abdominal pain and bloating. His symptoms were related to meals and as a result he had lost significant weight. He had previously undergone ileocolic resection with anastomosis and on this occasion you resect the area of the anastomosis and open the specimen shown below.

1. Describe the specimen shown.

The specimen is an opened segment of bowel with neoterminal ileum on the left and an ileocolic anastomosis towards the right. At the anastomosis there is evidence of stricturing with significant submucosal fibrosis and thickening that extends proximally for at least 10 cm. The mucosa overlying the anastomosis is deeply ulcerated. There are also linear ulcers in the mucosa of the ileum.

2. What are the histologic features of Crohn's disease?

Crohn's disease is a chronic inflammatory disease characterised by transmuarl involvement with mucosal damage, non-caseating granulomas and fissuring with the formation of fistulas.

Crypt abscesses occur but are not specific for Crohn's. Deep ulceration may be adjacent to relatively normal bowel wall indicative of the discontinuous distirbution of the disease. Sarcoid-like granulomas mayy occur in up to half of patients and can be found in any layer of the bowel wall and even in otherwise normal appearing bowel.

Deep fissures may lead to fistula formation between loops of bowel or other adjacent organs. Extensive submocosal fibrosis leads to sticture formation

3. What investigations would you perform prior to operation in this man?

It is important to confirm the diagnosis of recurrent Crohn's with stricture formation before embarking on resection. This can be done easily by colonoscopy and intubation of the terminal ileum. Colonoscopy also allows assessment of the extent of disease. Further assessment of the small bowel may require enteroscopy, radiologic enteroclysis or MRI (investigational at present).

Finally the patients overall fitness needs to be assessed. In particular the effects of malnutrition resulting from poor intake and malabsorption, chronic disease and probable chronic steroid use. Simple assessment is based on serum albumin and measurement of iron stores and vitamin B12. Other nutrients should be measured and replaced as appropriate.

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