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Case 42

Crohn's disease

Middle aged female with abdominal pain and altered bowel habit

This patient had a long history of gastrointestinal symptoms. On this occasion she presented with abdominal pain and altered bowel habit. A barium enema was performed. What does it show, and what is the likely diagnosis?

Findings

There is a short segment of abnormal descending colon with asymmetrical puckering of the mucosal surface, without stricturing.

Note also however that contrast has refluxed into the terminal ileum and small bowel, and there are several strictures present within it. One of these lies adjacent to the large bowel abnormality.

Diagnosis

Crohn's disease
Small bowel strictures and inflammatory mass, with secondary colonic involvement

Discussion

The asymmetrical puckered appearance of the mucosa resembling thumbprinting suggests an extrinsic, invading lesion, though a primary lesion such as colonic neoplasia would need to be excluded. Possible causes of thumbprinting include:

1. Ischaemic colitis: not this focal
2. Inflammation: Ulcerative colitis or Crohn's colitis
3. Infection: Amoebiasis, schistosomiasis, cytomegalovirus (immunosuppressed)
4. Malignancy: Focal primary lymphoma, metastases (especially if multiple)
5. Others: Endometriosis, amyloidosis, pneumatosis coli, diverticulitis, hereditary angioneurotic oedema.

Many of these will not produce the focal abnormality seen here. Furthermore the small bowel involvement is typical of Crohn's, and the patient had a long history of this condition.

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