Appendiceal Crohn’s disease

Case contributed by Mohamed El Deen
Diagnosis almost certain

Presentation

Acute onset RLQ pain x 24 hours. WBC is 11.000 cell/μL, ESR 120 mm/hr, and purified protein derivative (PPD) test -ve

Patient Data

Age: 35 years
Gender: Male
ultrasound

Sonographic images show target sign of inflamed retro cecal appendix with peri-appendicular hyperemia. There is also diffuse edematous thickened wall of both cecum and ileum. A picture suggesting inflamed appendix on top of ileocecal inflammatory process.

Ileocecal wall thickening and inflamed, there is also regional mesenteric fat stranding and multiple small regional mesenteric lymphadenitis.

The appendix did not fill with oral contrast may be related to sever wall edema of ileocecal valve region. But it was retrocecal and lateral on ultrasound. 

There is also a gall bladder stone as an incidental finding. 

Case Discussion

Appendiceal Crohn’s disease is not a common finding but should be excluded in the case of associated thickened gut wall in the ileocecal region. Supportive data and findings should be carefully studied including regional lymphadenitis.

History of tuberculosis and purified protein derivative (PPD) test result, WBC differential "either leukocyte or lymphocytic predominance". 

The importance of excluding tuberculosis, ulcerative colitis, and lymphoma in cases of appendicitis and cecal lesions is vital as surgical outcome "including the possibility of fistula formation" is different. 

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