Presentation
Abdominal pain, vomiting, diarrhea.
Patient Data
Cardiac borders, thoracic aorta, mediastinal borders, and lungs within normal limits. Right hemidiaphragm slightly elevated.
Air-fluid levels in multiple small bowel loops, more pronounced in right abdomen, one of which is dilated (right of midline at level of L1-L2).
Syndesmophytes at multiple levels. Sacroiliac joint narrowed bilaterally, perhaps even ankylosed. Skeletal findings consistent with ankylosing spondylitis.
Numerous non-enlarged mesenteric lymph nodes, particularly around the root of the mesentery.
Small bowel dilated up to 3.5 cm diameter with air-fluid levels, no apparent transition point. Levels in the transverse colon, small levels in the ascending colon. Several ileal loops show strongly enhancing walls of up to 9 mm in thickness. Hyperemia and fat stranding around said loops, Non-enlarged reactive regional mesenteric lymph nodes present. Minimal amount of free intraperitoneal fluid nearby. Findings highly suggestive of active Crohn disease.
Skeleton: Numerous syndesmophytes. Ankylosis of the left sacroiliac joint (SIJ) and narrowing of the right one with the creation of a small bony bridge. Findings consistent with ankylosing spondylitis (AS).
Case Discussion
The patient presented to the ED with vomiting and an exacerbation of abdominal pain from which he had been suffering for two weeks.
From the patient's file: Diagnosis of ankylosing spondylitis. Multiple episodes of abdominal pain, vomiting, and diarrhea for the past 3 years; suboptimal preparation for colonoscopy half a year ago. Fistulectomy for trans-sphincteric perianal fistula several months earlier. Leukocytosis of 14K, CRP 120.
CT abdomen showed all the hallmark radiological signs of both Crohn disease and ankylosing spondylitis.
Had been receiving Enbrel (etanercept) for 4 years. Started on Humira (adalimumab), which is efficacious for both conditions.
There is a known association between HLA-B27 and both inflammatory bowel disease (IBD) and ankylosing spondylitis (AS). This may explain IBD-associated spondyloarthropathy (SpA).
Disclosure: I, Dr Yair Glick, have no actual or potential ethical or financial conflict of interest in relation to the abovementioned medications. This case is not intended to be a personal endorsement or recommendation of these products.
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