Complicated Crohn disease

Case contributed by Yaïr Glick
Diagnosis certain

Presentation

Right flank pain for past 2-3 weeks.

Patient Data

Age: 20 years
Gender: Male
ct

Asthenic build.
Retroperitoneal abscess centered in the iliopsoas muscle, measuring 13.5 x 5.1 x 10.3 cm, containing air-fluid level and numerous gas bubbles. Elongated, cranially pointing retrocecal tubular structure with thick walls measuring 18 mm in diameter, probably representing the appendix.  Fistula from the base of the cecum, coursing posterior to the appendix and into the abscess. Anterosuperior extension of abscess into hepatorenal fossa. The cecum, ascending colon and terminal ileum show substantial wall thickening with narrowed lumen and pronounced fat stranding.
Splenule embedded in the pancreatic tail.

On same day

Fluoroscopy

Pigtail drain inserted under ultrasound and fluoroscopic guidance. Pus received and sent for culture.

1 week later

ct

The abscess has enlarged slightly, despite the pigtail catheter curled in its medial aspect, and now measures 15.1 x 6.4 x 10.3 mm. The amount of purulent content has increased, while the amount of gas has decreased. The cecum, ascending colon and terminal ileum still show significantly thickened walls and fat stranding.

18 days later

ct

In the interval, up to 3 drains were inside the retroperitoneal abscess. The first (pigtail) and another of the additional 2 were removed. Short JP drain left in situ. Tract from the abscess to the skin in right lower abdomen, where a drain was removed.
The abscess has slightly shrunk, especially its lower portion. Focus of contrast material in its anterior part, adjacent to the tract from the cecum.
Small subcapsular hepatic collection (abscess) at medial border of segments V-VI, appearing continuous with the anterosuperior extension of the abscess.
Persistent wall thickening of terminal ileum-cecum-ascending colon.

MRE done 10 days later

mri

MR enterography protocol used.

Wall thickening and abnormal enhancement of terminal ileum along a segment of 7.5 cm.  Striking wall thickening and luminal narrowing of cecum and ascending colon. Fistula between cecum and multilocular right iliac fossa abscess. Two percutaneous drains coursing though the abscess. The abscess itself has shrunk compared with the consecutive CT studies. gas bubble in its superior edge. Anterosuperior extension of abscess to area of gastric antrum has receded cf. latest CT study. The collection involves the medial edge of hepatic segments V-VI, forming a small subcapsular abscess. Edema of right iliacus muscle, soft tissue of inguinal region, and proximal adductors. Mild right hydroureteronephrosis; the right ureter is dilated down to the level of the pelvic abscess.

The appendix cannot be located. Transient jejunojenunal intussusception in left upper abdomen.

In summary:

  • appearance of active Crohn disease with ileocolic involvement and perforation complications
  • the right iliac fossa abscess and its anterosuperior extension have grown smaller
  • formation of small subcapsular abscess in hepatic segment V

Case Discussion

A young man presented with hitherto unknown Crohn disease, already with complications, due to procrastination in seeking medical care. After a trial of intravenous antibiotics and percutaneous drainage, underwent right hemicolectomy and started on biweekly Hyrimoz (adalimumab-adaz) subcutaneous injections.

Histopathology report:

  • colon (right colectomy): signs of chronic severe active transmural inflammation involving terminal ileum, cecum and proximal colon, with neuromatous hyperplasia, granulomas - findings favor the diagnosis of Crohn disease
  • no signs of dysplasia seen
  • proximal and distal resection margins without remarkable changes
  • Acute serositis
  • appendix: fibroadipose obliteration
  • Lymph nodes (pericolonic): hyperplastic lymph nodes (nine)
  • omentum
    • congestion of blood vessels
    • signs of inflammation with foci of necrosis

How to use cases

You can use Radiopaedia cases in a variety of ways to help you learn and teach.

Creating your own cases is easy.

Updating… Please wait.

 Unable to process the form. Check for errors and try again.

 Thank you for updating your details.