Introduction A 36-year-old patient was referred to general surgery with a change in bowel habit (constipation predominant), blood stained rectal discharge, right iliac fossa pain and weight loss.
Methods Investigations were performed:
CRP and platelet count were normal.
Coeliac autoantibodies were negative.
Sigmoidoscopy revealed faecally loaded rectum, no blood seen.
CT colonoscopy was normal.
The patient was referred to Gastroenterology. Over the course of the next year she was seen five times in outpatient clinic. She had now developed diarrhoea (with nocturnal symptoms).
Sigmoidoscopy including biopsies was normal.
Ultrasound of the abdomen was normal.
Pelvic ultrasound (to rule out a gynaecological cause), revealed a thickened caecum with a normal terminal ileum. A MR scan was advised.
MR scan showed a normal large and small faecally loaded bowel.
Colonoscopy was arranged but was not tolerated due to pain and it was abandoned at the splenic flexure. Biopsies of the left colon were normal.
Results The patient was seen again in Oct 08 with persistent diarrhoea, right iliac fossa pain and weight loss. These symptoms combined with the pelvic ultrasound showing thickening of the caecum suggested gut inflammation.
A trial of mesalazine was commenced with a dramatic improvement of symptoms. Intolerance to mesalazine developed (headaches) and the patient commenced budesonide 9 mg per day for 2 weeks, to be followed by 6 mg for 2 weeks and 3 mg for 2 weeks.
In May 09, the patient was reviewed and she stated that 6 mg of Budesonide daily controlled her symptoms but 3 mg did not. She was put back on 6 mg for the next 6 weeks and Azathioprine was commenced as long-term immunosuppression. The patient was intolerant to Azathioprine and has subsequently been maintained on long-term budesonide with good effect.
Conclusion MR scanning has been shown extensively to be very effective in diagnosing Crohn's disease including staging disease activity and complications (fistulating disease etc).1
High-resolution ultrasonography has also been shown to be a valuable tool for detecting small intestinal Crohn's disease. It has similar diagnostic values as CT. In early disease the sensitivity substantially decreases. In known Crohn's disease for following disease course, evaluating relapses and extraintestinal manifestations US is an excellent tool.2
This case highlights the dilemma of diagnosis vs management. The pragmatic approach taken here of treating this patient for Crohn's disease without a clear diagnosis is controversial as the long-term use of immunosuppression is not without risk. However, the treatment has allowed the patient to be symptom free for the first time in 2–3 years and she is willing to take the risks of treatment.