Unusual endoscopic appearance of Crohn's disease ... - Publicatio

LETTER TO THE EDITOR
Unusual Endoscopic
Appearance of Crohn’s
Disease: Another Face of
a Multifaceted Disease
To the Editor:
Crohn’s disease (CD) is a clinically
heterogeneous condition, with various
clinical presentations in different
patients. Endoscopic and transsectional
radiological imaging remains the mainstay
of evaluation and management of
the disease. The most characteristic
(‘‘elementary’’) endoscopic lesions of
CD are pseudopolyp, healed ulceration,
frank erythema, frankly swollen
mucosa, aphthoid ulceration, superficial
or swallow ulceration, deep ulceration,
and nonulcerated or ulcerated stenosis. 1
Although the most frequently observed
location of CD is the ileum and the
right side of the colon, a solely cecal
location with a tumor-like endoscopic
feature has never been described in the
literature.
A 27-year-old female was admitted
to our clinic in September 2010
with 2 weeks history of right lower
abdominal pain, nausea, and two loose
stools daily. Her medical history was
remarkable for an appendectomy in
2008. On physical examination mild
ileocecal tenderness was observed. The
laboratory findings showed a moderately
elevated C-reactive protein level
of 49.7 mg/L and erythrocyte sedimentation
rate of 36 mm/h. Abdominal
ultrasonography included wall thickening
of the cecum with enlarged lymph
nodes. The colonoscopy revealed an
unusual polypoid lesion between the
ileocecal valve and the appendiceal
orifice which resembled a tumorous
tissue (Fig. 1A,B). However, histology
disclosed intramucosal lymphoid infil-
Copyright VC 2012 Crohn’s & Colitis Foundation
of America, Inc.
DOI 10.1002/ibd.21943
Published online 31 January 2012 in Wiley
Online Library (wileyonlinelibrary.com).
FIGURE 1. Macroscopic and microscopic findings of the polypoid lesion in the cecum.
[Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
tration with nonnecrotizing epithelioid
cell granulomas suggesting indolent Bcell
lymphoma or sarcoidosis (Fig. 1C).
The ileum and the other part of bowel
were completely negative. Further histological
examination excluded lymphoma
and confirmed the presence of
inflammatory process. Due to the
patient’s continuous abdominal complaints,
the adjacent lymph nodes and
the tumor-like endoscopic finding of
the cecal lesion confirmed by a second
endoscopy, laparoscopic right hemicolectomy
was performed in January
2011. According to the surgeon’s opinion,
the macroscopic finding of the
resected cecum seemed to be malignant.
Surprisingly, the histological finding
of the resected tissue revealed granulomatous
fibrotizing colonic CD.
Further examinations were performed
to exclude other granulomatous diseases.
Nasal endoscopy excluded Wegener
granulomatosis; chest x-ray and
quantiferon test did not confirm tuberculosis.
Autoimmune markers and gastroscopy
was negative. The revision of
the tissue from the previous appendectomy
did not reveal CD. On the basis
of these data, we can conclude that the
diagnosis is truly CD with an extremely
rare appearance and location (solely to
the cecum without the involvement of
the ileocecal valve).
The diagnosis of CD requires the
patients’ history including symptoms,
intestinal and extraintestinal complications,
physical examination, laboratory
tests, endoscopy, histology, and imaging
methods if needed. 2 The endoscopic
appearance of CD is highly variable
and changes with disease activity and
duration. Polypoid lesion of the cecum
usually refers to colorectal malignancy,
carcinoid, or tuberculosis (TB). Since
CD and TB of the gastrointestinal tract
are clinically and radiologically similar
diseases, the differentiation of them is
challenging for clinicians. Although
the final diagnosis is based on histology,
colonoscopy still plays an important
role in establishing a suspected
disorder. Only few studies compared
the diagnostic value of endoscopy in
Inflamm Bowel Dis Volume 18, Number 10, October 2012 E1997

Farkas et al
CD and intestinal TB. One of them
found that anorectal lesions, longitudinal
ulcers, aphthous ulcers, and a cobblestone
appearance are significantly
more common in CD, and involvement
of fewer than four segments, a patulous
ileocecal valve, transverse ulcers,
and pseudopolyps were more frequent
in intestinal TB. 3 The study of Makharia
et al 4 revealed that skip lesions of
the colon (66% vs. 16.9%, P < 0.001),
aphthous ulceration (54.7% vs. 13.2%,
P < 0.001), linear ulceration (30.1%
vs. 7.5%, P ¼ 0.005), and superficial
ulceration (50.9% vs. 16.9%, P <
0.001) were significantly more frequent
in patients with CD compared to
patients with intestinal TB. Cobblestoning
of the colonic mucosa was
only seen in CD (16.9% vs. 0%, P <
0.001). Nodularity of the colonic
mucosa was significantly more common
in patients with TB than in those
E1998
with CD (49% vs. 24.5%, P ¼ 0.01).
According to this study, colonic
involvement was significantly more
common in CD than in TB; however,
there was no difference in the ileal or
ileocolonic locations. In our case, the endoscopic
appearance of the cecum suggested
most likely colonic tumor or intestinal
TB and least likely CD, since
none of the abovementioned diagnostic
endoscopic findings were detected. Such
an unusual macroscopic appearance of
CD has not been published before.
Klaudia Farkas, MD, PhD*
György Lazar, MD, PhD †
Laszlo Tiszlavicz, MD, PhD ‡
Laszlo Krenacs, MD, PhD §
Ferenc Nagy, MD, PhD*
Zoltan Szepes, MD, PhD*
Tibor Wittmann, MD, PhD*
Tamás Molnár, MD, PhD*
Inflamm Bowel Dis Volume 18, Number 10, October 2012
*First Department of Medicine
University of Szeged, Szeged, Hungary
† Department of Surgery
University of Szeged, Szeged, Hungary
‡ Department of Pathology
University of Szeged, Szeged, Hungary
§ Second Department of Medicine
University of Szeged, Szeged, Hungary
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4. Makharia GK, Srivastava S, Das P, et al. Clinical,
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Am J Gastroenterol. 2010;105:642–651.