This document presents a case study of a 24-year-old male who presented with dyspepsia and epigastralgia. Physical examination and laboratory tests revealed bowel loop dilation and edema. A diagnosis of possible Crohn's disease or tuberculosis was considered. The document discusses diagnostic workup and treatment approaches for inflammatory bowel disease, including imaging, serum markers, and medications like corticosteroids, mesalamine, and biologics.

1. Morning meeting:Morning meeting:
Presenter: PGYPresenter: PGY 胡子仁胡子仁
Supervisor:Supervisor: 葉子洪醫師葉子洪醫師

2. Basic data:
Name: 黃 X 民
Sex: male
Age:24 y/o
Marital status: unmarried
Occupation: military
Chart no:10423311
Date of admission: 2010/04/27

3. Brief history:
 He suffered from dyspepsia two weeks ago, and
progressed to epigastralgia recent three days.
 But, he denied fever, chills, nausea/vomiting,
headache/dizziness, hematemesis/hematochezia/
melena, etc.
 He also had experienced of hemoptysis and
dyspnea, cough with greenish sputum one month
ago.

4. Brief history:
Thus, he was attended our ER for help.
Physical examination presented normal active bowel
sound. Laboratory data showed monocytosis, CRP
elevated. KUB found bowel loop dilatation. Abdomen CT
discovered separate segments of wall edema and
luminal stenosis of the small bowel.
Thus he was admitted for further investigation.
picture

5. Past history and personal
history:
DM and HTN: denied
Smoking: denied
Alcoholic drinking: denied
 Allergy: denied
Travel history at recent six months:
denied.

6. Physical examination:
 Vital sign:T= 36.5 C ； P= 109beats/min ； R= 17
times/min. BP=118/73mmHg.
 General appearance: acutely ill-looking.
 Sclera: no icteric.
 Skin: no icteric .
 Chest :
 Inspection : normal quality of expansion,
symmetrically,no respiratory accessory muscle
use.
 Palpation : measured expansion.
 Percussion : resonance, normal decent of
diaphragms.
 Auscultation: clearly breath sounds.

7. Physical examination:
 Abdomen:
 Inspection : soft, no abdominal distention, no
flank bulging, no operation scar, no striae, no
superficial collateral vein, no umbilical hernia.
 Ausculation: normal active bowel sounds, no
bruit, no friction rub.
 Percussion :tympanic, no shifting dullness, liver
span: 7-9 cm over right mid-clavicular line.
 Palpation : soft, epigastric tender pain, no
Murphy's sign, no hepatomegaly, no splenomegaly,
no palpable masses, no knocking pain.
 Extremities= no pitting edema, no acrocyanosis.

8. back

9. CXR finding:

10. Laboratory data:

11. Diagnosis:
• Segmental bowel wall edema? Crohn’s
disease or tuberculosis or others?

12. Computed tomography (CT), tissue characterization, 74.12112, 75.12112 ● Intestines, CT, 74.12112, 75.12112.
RadioGraphics 2002; 22:109.Algorithmic approach to CT diagnosis of the abnormal bowel wall .

14. Discussion:IBD
Introduction:
 Inflammatory bowel disease (IBD) is comprised of
two major disorders: ulcerative colitis (UC) and
Crohn's disease (CD). UC affects the colon,
whereas CD can involve any component of the
gastrointestinal tract from the oral cavity to the
anus.
 The peak incidence of IBD occurs in patients
between the ages of 15 and 25 years.
Approximately 25 to 30 percent of patients with
CD and 20 percent of patients with UC present
before the age of 20 years.

19. Workup:
 We suggest upper GI series with small bowel
follow-through as the primary imaging technique
to assess for small bowel disease in a patient with
suspected IBD.
 This test may not be necessary if another imaging
modality (such as CT, MRI, or video-capsule
endoscopy) has already provided an adequate
examination of the small bowel. No imaging
modality is a substitute for thorough endoscopic
examination and histopathologic diagnosis.

20. Workup:
 If possible, the disease should be classified as
either CD or UC . If the disease type remains
uncertain after complete evaluation, the term
"indeterminate" colitis is used.
 Newer classifications schemes suggest using the
term "colonic IBD, type unclassified", reserving
"indeterminate colitis" for patients in whom the
type of IBD remains uncertain after colectomy
and pathological evaluation .

21. Workup:
 Features of CD — Features strongly suggestive of
CD include frank mucosal ulceration, narrowing or
obstruction, or enteric fistula. Other findings
include cobblestoning, cecal narrowing, bowel
rigidity, and bowel wall edema manifested by
separation of bowel loops ).
 The colonoscopic findings suggestive of CD
include small ulcers (aphthous lesions) in the
colon, discontinuous colitis with intervening areas
of normal mucosa ("skip areas"), a relative
decrease in the severity of inflammation in the
rectum ("rectal sparing"), and granulomas
identified on biopsy .

22. Workup:
 MRI and CT — Other imaging modalities, including
computerized axial tomography (CT), magnetic
resonance imaging (MRI), and nuclear medicine
studies are sometimes valuable in assessing for
complications of IBD, but their role in the initial
evaluation of a patient and the differentiation
between CD and UC has not been established .
 Like barium contrast studies, MRI can detect
small bowel disease in areas of the small intestine
that are inaccessible to endoscopy.

23. Workup:
 Certain serum antibodies may be helpful for
screening for IBD and discriminating UC from
CD .
 ASCA and P-ANCA — Anti-Saccharomyces
cerevisiae (ASCA) antibodies are found in 40 to
80 percent of individuals with CD, tend to
identify patients with disease of the terminal
ileum and cecum, and are unusual in patients with
UC. Thus, a positive ASCA test in a patient with
IBD suggests the diagnosis of CD. The sensitivity
and specificity of P-ANCA and ASCA tests are
similar in adults and children with IBD.

24. Workup:
 Atypical perinuclear antineutrophil
cytoplasmic antibodies (atypical P-ANCA,
ie, not directed against myeloperoxidase)
can be detected in 60 to 80 percent of
children and adults with ulcerative colitis
compared to 10 to 27 percent of adults
with CD (in whom only low titers may be
present).

25. Workup:
 Anti OmpC antibodies — The anti-OmpC antibody
has been identified as a potential serologic
marker of IBD. The OmpC is an outer membrane
porin, E. coli protein that is immunoreactive to P-
ANCA monoclonal antibodies .
 Anti CBir1 — Antibodies to the bacterial flagellin
CBir1 are found in approximately 50 percent of
individuals with CD, and have been associated with
small bowel, internal-penetrating and
fibrostenosing patterns.

26. Treatment:
Acute attacks:
 Severe disease should be referred to a
specialist for intravenous corticosteroid
treatment and consideration of total parenteral
nutrition and antibiotic therapy.
 Mild-to-moderate disease requires oral
corticosteroid (prednisone) treatment with or
without an oral aminosalicylate(5-ASA). Oral
budesonide has also been found to be effective
in mild-to-moderate Crohn's disease, with
equal improvement rates for budesonide and
prednisone.

27. Treatment:
 Mild disease is treated with an oral
aminosalicylate. Metronidazole is an appropriate
alternative.
 Infliximab has been used for moderate-to-
severe Crohn's disease that is unresponsive to
corticosteroid management and to aid healing
of perianal fistulas.
 Tacrolimus has been used in refractory
corticosteroid-dependent cases.
 Adalimumab and natalizumab are approved for
the treatment of moderate-to-severe disease.

28. Treatment:
 Maintenance therapy:
 Mesalamine(5-aminosalicycle, 5-ASA) is generally the
preferred maintenance therapy because it is associated
with fewer adverse effects than corticosteroids.
Mesalamine enema may be used in disease that is limited
to the rectosigmoid region.
 Corticosteroids (prednisone and budesonide) should not be
considered as maintenance therapy because long-term
adverse effects are problematic. Corticosteroid enema
use should be limited to disease of the rectosigmoid
region; systemic absorption may be significant, and
mesalamine is generally preferred.

29. Treatment:
 Mercaptopurine and azathioprine are excellent
alternatives where mesalamine has failed.
 Methotrexate may be used in selected patients
with refractory, corticosteroid-dependent
Crohn's disease.
 Symptomatic treatment:
 Endoscopic stricturoplasty - colonic strictures
secondary to chronic scarring from Crohn's
disease can occasionally be dilated with
symptomatic relief.

30. The end!The end!
Thanks for your attention?Thanks for your attention?