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Case 29: Abdominal pain and diarrhoea.

A 32 year old man presented after four days of fever, abdominal cramps and diarrhoea. Due to right sided abdominal tenderness and the possibility of appendicitis a CT was performed.

Further Information.
He says that he occasionally gets crampy abdominal pains, and also suffers joint pains in his knees, hips and in his right lower back.

1. What does it show?

A right sided colitis. There is confluent thickening of the entire right colon. The mucosa is grossly thickened and protruding into the colonic lumen.


2. What does his plain Xray show?

With this history in mind, the xray does show, right sacroileitis. There is loss of the usual joint space, and periarticular sclerosis. With all the above clinical information, the diagnosis of inflammatory bowel disease seems likely in this patient.




Extraintestinal manifestations in inflammatory bowel disease

There are many extraintestinal manifestations in inflammatory bowel disease. Approximately 2% of ulcerative colitis patients will develop primary sclerosing cholangitis, a cholestatic liver disease diagnosed by the appearance of extrahepatic and intrahepatic strictures on a cholangiogram. Primary sclerosing cholangitis is seen more often in ulcerative colitis than in Crohn's disease patients.9 Other hepatic manifestations of inflammatory bowel disease include fatty liver, chronic active hepatitis, amyloidosis, and drug-induced disease from medications used to treat inflammatory bowel disease (steroids, azathioprine, 6-mercaptopurine [6-MP], or sulfasalazine).

Erythema nodosum, seen in up to 3% of patients, is characterized by raised, tender, erythematous nodules appearing typically on the extremities. Pyoderma gangrenosum, a rare, ulcerating, and necrotic lesion, is seen in both Crohn's disease and ulcerative colitis. Arthritis usually is seronegative, mono- or pauciarticular, and asymmetric. The large joints are most often affected, and there is no synovial destruction. Ocular manifestations include blurred vision, eye pain, photophobia, and keratitic precipitates. Patients are susceptible to nephrolithiasis from calcium oxalate stones. Patients with uveitis often have HLA-B27, whereas patients with episcleritis and iritis usually do not. Cerebrovascular accidents and other thromboembolic events can result from hypercoagulability secondary to chronic inflammation or to other inherited syndromes such as the factor V Leiden mutation.

Ref: Cleveland Clinic inflammatory bowel disease





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