Acute-on-chronic Crohn disease with enteroenteric fistula

Case contributed by Dr Vinay V Belaval


History of abdominal pain and recurrent loose stools.

Patient Data

Age: 60 years
Gender: Male

Contrast enhanced images of abdomen show moderate circumferential wall thickening of terminal ileum for a length of 5.0 cm and maximum wall thickness of 8 mm showing increased surrounding mesenteric vascularity (comb sign). There is severe narrowing at the level of thickening (representing stricture) with resultant moderate focal (<4 cm) distal ileal loop dilatation (3.7 cm in diameter). The dilated loop shows mottled intraluminal contents. 

There is hypertrophy of peri-ileal fat in right iliac fossa. 

Mucosal ulcers are seen in inflamed terminal ileum. 

Focal areas of enteroenteric fistula are noted between the narrowed and dilated loops of terminal ileum.

No enterocutaneous fistulae noted.

These features are consistent with active (mucosal ulcers, enhancing wall thickening and comb sign) on chronic (stricture of terminal ileum and enteroenteric fistulae) Crohn disease.

Few small reactive mesenteric lymph nodes are noted in right iliac fossa.

Multiple simple hepatic cysts and trace bilateral pleural effusions are also noted. 

Case Discussion

60 year old male presented with recurrent loose stools and abdominal pain. He underwent contrast enhancement CT scan of abdomen.

CT abdomen showed enhancing wall thickening of terminal ileum with inflammatory stricture, increased surrounding mesenteric vascularity, mucosal ulcers and hypertrophy of peri-ileal fat in right iliac fossa. There were focal areas of enteroenteric fistulae between the narrowed and dilated portions of inflamed terminal ileum. 

These features are consistent with acute-on-chronic Crohn disease with enteroenteric fistula.    

Assessing disease activity can be done by CT or MRI. MR enterography is useful in distinguishing between the stricture and transient narrowing of peristaltic segment of bowel. 

CT abdomen is also performed prior to capsule endoscopy to rule out bowel strictures, which are a contraindication to the use of a capsule endoscope.

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Case information

rID: 66686
Published: 2nd Mar 2019
Last edited: 16th Oct 2020
Inclusion in quiz mode: Included
Institution: Belcity Scan and Diagnostic Centre

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