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9 (Inflammatory Bowel Disease and Mimickers)

CASE 1Female, 69 yrs oldC.C: abdominal pain(onset: 5 days ago)Lab finding: non-specificPMHx: nonspecific69 5 abdomina pain . lab finding . 2

Arterial phase abdomen CT arterial phase .

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Portal phase4

Case summaryIleocecal wall and three short segmental ileal wall thickening with bowel dilatation.Homogeneous wall enhancement on portal phase. No perienteric infiltration of fat.Rt omental infiltration and nodules.No ascites or LN enlargement.

Differential diagnosis Relatively homogeneous enhancement Multiple wall thickening with skip lesionDistal ileumwithmarked narrowingeither neoplastic or non-neoplastic

(more frequent with non-neoplastic entities)Crohns disease

GI GVHD

Mesenteric vasculitis

Tuberculous enteritis

Lymphoma

MetastasisCrohns disease

Tuberculous enteritis

Behcet disease

AIDS related infection(CMV, actinomycosis)

Lymphoma

Metastasisroutes by which secondary neoplasms reach the small bowel include direct extension (i.e. colonic, pancreatic and gastric cancers), intraperitoneal spread (i.e. ovarian cancer) and lymphohaemato - genous embolization (i.e. melanoma, lung and breast cancer). Melanoma is the most common malignancy to metastasize to the small intestine, although testis, lung, breast and ovarian cancers also frequently involve the small intestine by metastatic spread 7

Differential diagnosisPossibility Crohns disease

Low possibility due to no typical finding, such as mesnteric side ulceration, no pseudosacculation, no fistula formation, no comb sign, no fibrofatty mesenteric change, no mural stratificationLymphoma

Low possibility due to significant obstruction sign, no significant lymph node enlargementMetastasis

Low possibility due to very rare disease entity, no history of underlying primary malignant lesion, such as stomach cancer, melanoma, breast cancer, lung cancerTuberculous enteritis

Relatively high possibility due to circumferential wall thickening, cecal involvement, multiple short segmental involvementBut no tuberculous lymphadenopathy in this case routes by which secondary neoplasms reach the small bowel include direct extension (i.e. colonic, pancreatic and gastric cancers), intraperitoneal spread (i.e. ovarian cancer) and lymphohaemato - genous embolization (i.e. melanoma, lung and breast cancer). Melanoma is the most common malignancy to metastasize to the small intestine, although testis, lung, breast and ovarian cancers also frequently involve the small intestine by metastatic spread 8

Colonoscopy findingIC valve 3cm length stenotic lesion of terminal ileum, mucosal nodularity, hyperemia, edma . ICV 3cm partial stenosis of TI (appr. length 3cm) PCF scope scope . ICV 10 15cm . Partial stenosis focal ulcer circumfernetailly 270 mucosal nodularity, hyperemia, edma . 6 (A) Cecurm appendical oriice mild erythema edema . biopsy hard subepithelial lesion . 6 . (B) TI ICV cecum involve lymphoproliferative disease (such as lymphoma) , NSAIDs-induced enteropathy . Tbc eneteritis . There were polyps. Site : Transverse colon, Shape : IIa, Size : 4 mm Tx : Biopsy removal (C) Site : Sigmoid colon, Shape : Isp, Size : 8 mm Tx : EMR (D) There was multiple diverticulosis at simoig colon # Impression r/o lymphoproliferative disease r/o NSAIDs-induced enterophaty DDx. intestinal Tbc, less likely Small bowel partial stenosis at TI (length 3cm) (TI (3cm above ICV, AV 90cm) focal ulcer with circumferential mucosal edema biopsy x 6 times with Tbc study(A). cecum appendical orifice biopsy x 6 times(B)) Polyps (C D) Diverticulosis, SC 10

Colonoscopy findingCecurm appendical oriice mild erythema edema . biopsy hard subepithelial lesion . . ICV 3cm partial stenosis of TI (appr. length 3cm) PCF scope scope . ICV 10 15cm . Partial stenosis focal ulcer circumfernetailly 270 mucosal nodularity, hyperemia, edma . 6 (A) Cecurm appendical oriice mild erythema edema . biopsy hard subepithelial lesion . 6 . (B) TI ICV cecum involve lymphoproliferative disease (such as lymphoma) , NSAIDs-induced enteropathy . Tbc eneteritis . There were polyps. Site : Transverse colon, Shape : IIa, Size : 4 mm Tx : Biopsy removal (C) Site : Sigmoid colon, Shape : Isp, Size : 8 mm Tx : EMR (D) There was multiple diverticulosis at simoig colon # Impression r/o lymphoproliferative disease r/o NSAIDs-induced enterophaty DDx. intestinal Tbc, less likely Small bowel partial stenosis at TI (length 3cm) (TI (3cm above ICV, AV 90cm) focal ulcer with circumferential mucosal edema biopsy x 6 times with Tbc study(A). cecum appendical orifice biopsy x 6 times(B)) Polyps (C D) Diverticulosis, SC 11Pathology reportColonoscopic biopsyA. Terminal ileum: Signet ring cell carcinoma in the mucosa and submucosaB. Cecum: Signet ring cell carcinoma in the mucosa and submucosa Multifocal signet ring cell carcinoma Signet ring cell carcinoma of intestineInvolve many organs, including the stomach, gallbladder, breast, lung, pancreas, genitourinary tract, esophagus and large intestine.

But most frequently in the stomach. Less commonly in the rectosigmoid colon.

Very poor prognosis. Early peritoneal seeding, low incidence of liver metastasis

Signet ring cell ca. of small bowel is extremely rare. Characteristics of this tumor are seldom described.Recognized in an advanced stageThe 5-year survivalrate is 27%, compared with 58%and 63% for mucinous carcinomasand the usual adenocarcinomas, respectively.13Several case reportsSignet Ring Cell Carcinoma Of The Ileum The Internet Journal of Surgery. 2009 Volume 25 Number 1

Our caseMultifocal signet ring cell carcinoma in cecal and ileum

14CASE 2Female, 31 years old C.C: 2004 Crohns disease . 2006 , F/U . fever, abdominal pain . CRP 59.7mg/L

2013.16

Aug 5, 2015Case summaryCurrentMultiloculated abscesses adjacent to thickened distal ileal loop, involving appendix tip.Severe pelvic fat infiltration.Multiple enlarged lymph nodes at ileocolic chain.

PastMultisegmental asymmetric wall thickening with hyperenhancement in distal ileum.Comb sign, pseudodiverticulum of small bowel.Prominent inflammatory stricture at distal ileal loop.

19Differential diagnosisDDx. 1. Active Crohns disease with complicated abscesses formation.

DDx. 2. Appendiceal tip perforation with periappendiceal abscess, less likely

Laparoscopic ileocecectomyThickned distal ileum loop and Inflammatory lesion

ileumcecumDrainge op . 22Pathology report Main diagnosis: Signet ring cell carcinoma with neuroendocrine differentiation (mixed adenomeuroendocrine carcinoma)Location: distal ileum, gross type: ulcerativeSize: 5.9x4.9cmDepth of invasion: Invades subserosa (pT3)Resection margin : Free of carcinoma Lymph nodes, regional (5/17): Metastasis in 5 out of 17 regional lymph nodes (pN2a)Lymphovascular invasion: Not identifiedAssociated lesions: Mucosal atrophy with histologic evidence of chronic crypt change, pyloric gland metaplasia, and non-caseating granuloma, consistent with Crohn's diseaseAppendix: Free of carcinoma

Note) carcinoma .

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Small bowel cancerin Crohns disease patientSmall bowel cancer in Crohns disease patient12-60-fold increase in risk of small bowel cancerArising from IC valve and stricture segment Almost adenocarcinoma, signet ring cell ca is very rare signet ring cell ca

Diagnosis of small bowel cancer in Crohn patient , ,

2 . , , , . , , .3,4 25Small bowel cancerin Crohns disease patientRisk factor of small bowel cancer in crohn ptStricure, fistula formationDuration of the disease (at least 10 years)Diagnosis before age 30 years Male Case reportA Case of Small Intestinal Signet Ring Cell Carcinoma in Crohns Disease 2007;50:51-55

Small bowel cancerin Crohns disease patientCT finding suggesting small bowel cancer Sacculated loop with asymmetric thickening. Loss of mural stratificationModerate enhancement after IV contrast Enlarged adjacent mesenteric lymph nodesLack of response in healing of fistula on medical therapy, signify presence of carcinoma