Nov 2019
• Large volume watery loose stools (10-12 episodes) (nocturnal) with occasional drops of blood, tenesmus and urgency
• No associated pain abdomen, borborygmi, fever or vomiting
• UGIE- normal
• CT enterography- normal
• Sigmoidoscopy- diffuse loss of vascular pattern with erythema and multiple superficial ulcers in rectum and sigmoid
• HPE- moderately dense infiltrates of plasma cells, lymphocytes and neutrophilic focal cryptitis, crypt abscessesà Early IBD
• Steroids and Mesalamine
Feb 2020
• Peri umbilical colicky pain abdomen with distension à better with vomiting (non bilious) or stool passage
• AZT intolerance (TPMT positive)
• F. calprotectin 128
• CMV IgM and DNA PCR- negative
• ANA, anti ds DNA, ASMA, anti LKM1 negative
• Anti tTG negative
• Ileo colonoscopy and CT enterography- normal
• Random biopsies- chronic active infl- consistent with UC till TI
June 2020
• UGIE- nodularity and scalloping in D2
• HPE- focal flattening of epithelium with intraepithelial neutrophilic infiltration; cryptitis, crypt abscess, crypt loss, dense lymphoplasmacytic infiltration in lamina propria, basal plasmacytosis; no granuloma/ dysplasia/ malignancy
• Ileocolonoscopy- normal
• Random HPE- chronic ileitis with activity, crypt loss, increased IELs, chronic proximal predominant colitis with activityà ?Autoimmune enteritis/ IBD
• Video capsule enteroscopy- diffuse loss of small intestinal folds and mucosal atrophyà ? Tropical sprue
• MRCP- GB sludge; normal biliary tree
• ANA profile negative
• Steroids, Pentasa
• Nitazoxanide, antibiotics
On evaluation at AIG HOSPITALS
• CBP normal (Hb 10.3; MCV 102)
• B12- 1008; Vit D 9.2; Iron- 40
• ESR 7
• LFT normal except Albumin 2
• Anti tTG negative
• OGD- D2 scalloping (HPE- mild villous atrophy without IELs)
• Ileo colonoscopy- mucosal edema with patchy vascularity in recto- sigmoid (HPE- mild active infl)
• USG abdomen and CT enterography- normal
Ø 20 years girl on wheat and milk free diet
Ø Large volume watery diarrhea- non bloody; lower abdominal pain with vomiting
Ø D2 scalloping- no increase in IELs
Ø Nonspecific recto sigmoid erythema
Currently in ICU with hypotension
Kindly share your comments?
Antienterocyte antibodies would be
1. Unless there has been clear benefit from prednisone would stop treatment with mesalamine and the azathioprine until a definitive diagnosis of Inflammatory Bowel Disease can be made.
2. Stool for an electrolyte
3. Fecal elastase and pH
4. Fecal alpha-1 antitrypsin
5. 48-hour stool on a high fat diet to assess for fat malabsorption
6. Check other fat soluble vitamins--A, E and PT INR and folate level
6. Agree with balloon enteroscopy for tissue acquisition of the jejunum. Biopsy should be stained for amyloid
7. Check C1 esterase inhibitor panel
8. Document whether there is any similar history in the family to suggest familial Mediterranean fever
By Dr. Kane, Sunanda V.,