Granulomatosis Colitis
Presented by
Dr. Leon Wolf
History
C.C. Anemia and HO + 45 yo male asymptomatic PMH h/o goiter, Rx Synthroid FH CAD DM Colonic polyps SH born outside of USA, postal worker ROS w/o wt loss, fever
w/o cough, sputum hemoptysis
Physical Exam
Healthy appearing wt.220 T.98.6 HEENT R. neck fullness Lungs clear Abd soft w/o masses, LSKK Rectal w/o masses, HO+ Ext w/o joint fullness or tenderness Skin w/o rashes
LAB
Hgb 10.6, MCV 77 WBC 8,900 ; normal differential CMP normal CEA 1.4
ENDOSCOPIC EVALUATION
Colon cecal villous,nodular friable lesion EGD gastric erythema
esophageal nodule Microscopic Colon: granulomatous colitis
Stomach: mild gastritis
Esophagus: papilloma
Clinical Course
RX Pentasa, iron CXR negative SBFT negative CTABD/PELVIS negative PPD positive 20yrs ago
Re-Colonoscopy
Villous, nodular lesion Open ileocecal valve Ileal lymphoid hyperplasia Cultures AFB,Fungus, O&P Stains
Diseases to Consider in the Differential Diagnosis
Gastrointestinal diseases
– Inflammatory bowel disease
Crohn’s disease Ulcerative colitis
– Nodular lymphoid hyperplasia
– Celiac disease– Necrotizing enterocolitis
Gastrointestinal diseases continued
– Behçet’s disease– Eosinophilic
gastroenteritis– Hirschsprung’s disease
with necrotizing enterocolitis
– Neoplasms– Anatomical or vascular
abnormalities
Diseases to Consider in the Differential Diagnosis Continued
Hematologic diseases– Chronic granulomatous
disease– Langerhans’ –cell
histiocytosis– Familial hemophagocytic
lymphohistiocytosis
Systemic inflammatory diseases
– Sarcoidosis– Wegener’s
granulomatosis– Juvenile
dermatomyositis– Juvenile rheumatoid
arthritis– Systemic lupus
erythematosus
Diseases to Consider in the Differential Diagnosis continued
Infectious diseases– Mycobacterium tuberculosis infection– M. avium infection– Yersinia infection– Giardia lamblia infection– Tropheryma whippelii infection– Bartonella henselae infection
Differential DX
Yersinia Sarcoidosis Crohn’s disease Tuberculosis
Yersinia
Gram negative rod Contaminated milk, milk products Acute manifestations Enterocolits most common <5 yo Adenitis, ileitis >5 yo Bacteremia in pts underlying disease Reiter’s syndrome Self limited 3 to 4 wks
Sarcoidosis
Gastrointestinal involvement uncommon other than liver granulomatosis
Stomach primarily,bleeding ulcerations Small intestine nodal or lymphatic blockage Esophageal obstruction lymph nodes or
infiltration Pulmonary or renal involvement with above
Tuberculosis
Koch 1882 ID bacillus Primary pulmonary disease Pre antiboitics 55-90% GI involvement Proportional to pulmonary disease Post antiboitics GI disease have <50%
pulmonary tb evidence
Tuberculosis organisms
M. tuberculosis M.bovis (M. avium)
Patients At Higher Risk
Immigrants (travel endemic areas) AIDS Urban poor Living on reservations Prisoners NH residents
Gastrointestinal Areas
Ileocecal/ileal approx 75% Asc.colon appendix approx 20% Uncommon jejunum,stomach,esophagus,
sigmoid/rectum, anal Multiple areas-skip areas
Clinical Sx and Exam
Non-specific sx 80-90%
pain
wt loss
diarrhea/constipation
blood in stools PE abdominal mass
perianal lesions
Complications
Hemorrhage Perforation Obstruction Fistula formation Malabsorption
Endoscopic Findings
Ulcerative 60% Hypertrophic 10% Mixed 30% Circumferential ulcers Scarred open IC valve
Radiological Findings
BE/SBFT ulcers
thickening/distortion
stenosis
pseudopolyps CT adenopathy-central necrosis
mass
calcified nodes
Diagnosis
Stain <20% PCR 80% Culture <30% mucosal biopsies
? % surgical specimen esp node
n.g. stool esp with pulm disease
Presumptive +PPD, +CXR Therapeutic Response
Clinical Course
Iron RX increase hgb felt less dizzy + AFB culture M.gordonia
Ten Diseases Doctors Miss Reader’s Digest Feb 2003
1. Hepatits C2. Lupus3. Celiac Disease4. Hemochromatosis5. Aneurysm6. Lyme Disease7. Hypothyroidism8. Polycystic Ovary Syndrome9. Chlamydia10. Sleep Apnea