Crohn

1

Crohns Disease Presenting as Intestinal
Parasites I got worms Poster by Jared
Halterman, Kade Rasmussen DO, and Joseph
Dougherty DO
Discussion
Case Summary
Crohn's Disease (CD) is an inflammatory,
immune-mediated condition which may affect any
portion of the GI tract from the mouth to the
anus, most commonly the ileum and cecum (50).
Pathophysiology is not clearly defined, but
likely involves both genetic and environmental
factors. Incidence is 5-10 cases per 100,000 with
app 25 occurring children younger than
18. Presentation is variable and often
nonspecific. In children intestinal symptoms
include growth failure, weight loss, diarrhea,
abdominal pain, abdominal mass, bowel
obstruction, rectal bleeding. Extraintestinal
manifestations include fever, arthralgias,
uveitis, anemia, clubbing, oral ulcers.
Diagnosis typically involves extensive workup to
rule out other diseases. Incorrect initial
diagnosis is not uncommon due to the variability
in early symptoms, though possible parasitic
infestation is presumed to be a less common
presentation. That we are aware, our patient
denied typical previous signs or symptoms before
presenting with SBO secondary to terminaI iliel
inflammation requiring ileocecectomy.
Treatment is based on symptoms and consist of
diet control, anti-inflammatory medications
(sulfasalazine, corticosteroids),
immunosupressents (azathioprine), antibiotics
when necessary, anti-diarrheals or laxatives,
pain control and surgery as a last resort.
A 14 year-old male with abdominal pain and
vomiting for three days was transferred from a
rural ER to the emergency department at a
tertiary childrens care center with the
diagnosis of parasitic worm infection of the
small bowel. The patient had initially presented
to the transferring facility the previous day.
Based on physical exam he was diagnosed with
gastroenteritis and discharged home. He returned
the next day with worsening symptoms. Labs and
CT scan of the abdomen were performed, leading to
diagnosis and transfer. Pertinent medical and
social histories were negative except for a
recent trip to Puerto Rico two months prior. On
exam vitals were within normal limits, membranes
were slightly dry. There was periumbilical
tenderness with rebound and guarding. Discs with
CT imaging accompanied the patient and were
reread by pediatric specialists. Impression was
as follows Dilated loops of small bowel at
the level of the terminal ileum with wall
thickening, multiple ovoid shaped densities with
peripheral lucency/gas in the distal small bowel,
probable resulting in obstruction at the level of
the terminal ileum/ileocecal valve. These
intralumenal densities could represent parasitic
disease or represent retained ingested material.
The colon is collapsed and there is free fluid in
the abdomen and pelvis. There are multiple
mesenteric nodes which may be reactive. In the
ED the patient received pain medications, IV
fluids and an NG tube placed. Patient was taken
by surgery for an exploratory lap, the end result
of which was ileocecectomy with anastamosis.
Pathology of the removed segment showed full
thickness colitis with granulation tissue, and
retained vegetable material. Final diagnosis was
new onset Crohns Disease leading to small bowel
obstruction.
References 1 Griffiths, AM, Hugot, JP. Crohn
Disease. In Pediatric Gastrointestinal Disease
Pathopsychology, Diagnosis, Management, 4th ed,
Walker, WA, Goulet, O, Kleinman, RE, et al (Eds),
BC Decker, Ontario, 2004. p. 789. 2 Galbraith SS,
Drolet BA, Kugathasan S, et al. Asymptomatic
inflammatory bowel disease presenting with
mucocutaneous findings. Pediatrics 2005
116e439. 3 http//www.cdc.gov/ibd/ 4
http//www.mayoclinic.com/health/crohns-disease/DS
00104
Cobblestoning inflammation
Terminal Ileum w/ granulation tissue, gross and
on microscopy