Dr.Venkatesh Kumar, Dr.Vinitha Prasad, Dr.StefySunny , Dr.Shela Sany ,
Dr.C.Jayakumar
Six years old male otherwise-normal child but with the history of chronic constipation presented with two episodes of non-projectile and non-Bilious vomiting .
Historically other systems were normal
General examination was within normal
limits.
Auxology revealed Grade-2 PEM,Grade –1 stunting with Grade-1 wasting.General examination done did not reveal any perianal skin tags or perianal fistula.
Systemic examination showed
doughy,distended abdomen but bowel sounds were present
One month back,child was on inpatient treatment for Constipation
associated with fever and
three days later ,he developed lethargy,peri orbital puffiness and pedal edema and that resulted in his referral to our hospital
Due to hypoproteinemia,edema and chronic constipation evaluation was
done for Nephrotic syndrome which was negative.
ECHO normal
Tissue transglutaminase and Anti-
Endomyseal antibody-were negative,
But Fecal cal protectin
showed elevated levels(627) values
Differentials
1.Inflammatory bowel disease-Crohn’s disease
2.Celiac disease
3.Hirschsprung’s disesae
4.Congenital aganglionic megacolon
5.Chaga’s disease
Investigation:
CBC:low normal total counts(TC:6.12 ku/ml,N-57.5%,L-31.7%,Hb-9.6 gm/dl,Plt-570 ku/ml
LFT showing hypoalbuminemia Total protein 7.6gm%Albumin:3 gm/dl)
Thyroid function test was within normal limits.
USG Abdomen which showed extensive gaseous distension on right
side ,few dilated bowel loops seen with good peristalsis.
Anorectal manometry was normal.
Erect AbdomenX-ray showed Fecal loading with dilated large bowel loops present.
Barium enema:showed diffusely dilated large bowel loops with
no evidence of Hirschsprung’s disease
Delayed image taken 24 hours post procedure showed
significant retention of contrast with diffusely dilated large bowel loops
Oesophagoduodenoscopy done was normal.
Colonoscopy showed Mucosal edema over rectum and left colon,dilated large bowel loops ,biopsies were taken.
Colon biopsy:lamina propria showing few pericryptal histiocytes.Deeper levels showing small,ill formed superficial
non-necrotising granuloma.
Rectal biopsy: Rectal mucosal fragments showing focal erosions
,lamina propria show few pericryptal histiocytes and scattered
neutrophils with associated focal crypt abscess.
Diagnosis: Inflammatory Bowel disease(Crohn’s disease)
Discussion: Main feature of Crohns is patchy segmental
transmural chronic inflammation of gut from oral cavity to anus.
GI manifestation include abdominal pain and
tenderness,anal fistulas,skin tags.Non specific symptoms include fever,anorexia .
Extra-intestinal manifestation include
aphthous stomatitis,arthralgia, necrotic skin lesions,
Musculoskeletal involvement ,Growth failure and rarely renal
problems.Investigations include CBC,ESR ,Xray may reveal
intestinal obstruction,bowel dilatation and upper GI
studies(single and double contrast).Double contrast Barium
enema -shows skip lesions,loss of haustration,narrowing of
colon,cobblestone appearance.Endoscopy reveals shallow
aphthous gastric ulcers or deep penetrating ulcers.Intestinal
biopsy shows changes in terminal ileum.
Treatment :Treatment of malnutrition and induction of
remission,Steroids,Anti inflammatory
drugs,Immunosupressants,Antibiotics and Bile acid binding
agents.
1)Induction of remission:Exclusive enteral nutrition(EEN)-for
children with luminal CD.In moderate to severe luminal CD:Oral
corticosteroids(Prednisolone 1-2mg/kg/day). In mild luminal
CD:Azithromycin and rifaximin can be used.In mild to moderate
ileocaecal CD:Budesonide can be used.Steroids are given at full
dose of 2-4 weeks followed gradual tapering over the next 8
weeks.For perianal CD-Metronidazole(10-20mg/kg/day)and
ciprofloxacin(20mg/kg/day) are used. In steroid refractory
CD:Anti TNF therapy with agents like Infliximab is used for
induction of remission
2)Maintenance of remission:Thiopurines are the recommended
agents for maintaining steroid free remission in children with
CD. Methotrexate can be used as monotherapy for
maintenance of remission.Can also be used as a second line
drug in children with Thiopurine failure.Dosage:15mg/m2
weekly as subcutaneous injection.Oral folic acid is given 24
hours after methotrexate is given.Anti TNF agents:for
maintaining remission in children with chronic active luminal
CD.Maintenance dose:5mg/kg every 8 weeks
INDICATIONS FOR SURGERY IN CD:
Failure of medical therapy,Growth failure despite maximal
therapy,Extraintestinal involvement.
Take home message:Child presenting with abdominal should not always be considered as Intestinal obstruction and managed accordingly.But detailed evaluation should be carried out not to miss chronic conditions like IBD,which can improve the prognosis of the patient.
