Case Studies
Case 14.4 Crohn's disease
A 30-year-old woman was admitted with a 4-week history of increasing bloody diarrhoea and abdominal pain; she had lost 3kg in weight. She smoked 25 cigarettes a day. On examination, she was not clinically anaemic and, apart from a temperature of 37.8°C and some tenderness over the right iliac fossa, there were no abnormal physical signs. The perineum was normal but sigmoidoscopy to 15cm showed a red, granular mucosa with mucopus and contact bleeding. Laboratory investigations showed a low haemoglobin (108g/l) with a raised CRP (67 mg/l) but a normal white-cell count. Urea and electrolytes, serum vitamin B12, folate, iron, ferritin and iron-binding capacity were normal. Her total serum proteins were 54g/l (NR 62-82) with a serum albumin of 29g/l (NR 35-50). Antibodies to neutrophil cytoplasmic antigens (ANCA) were not detected. Faecal examination and culture revealed no ova or Campylobacter. Clostridium difficile toxin was absent from the stools.
The rectal biopsy taken at sigmoidoscopy showed a small area of ulceration of the surface epithelium with considerable mucopus. Many crypt abscesses were present. The lamina propria contained a heavy infiltrate of lymphocytes, plasma cells and macrophages. Two non-caseating granulomas were present. The appearances were those of Crohn's disease affecting the colon. A small-bowel barium infusion and a colonoscopy were performed to assess the extent of disease. Inflammatory strictures were seen at a number of separate sites (skip lesions) in the ascending and transverse colons. She was treated with corticosteroids and a 3-month course of metronidazole with symptomatic improvement. She was strongly advised to stop smoking.
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