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Case 48

Small bowel Crohn's disease

Weight loss & anaemia in a young man

Rachel Connor

This 19 year old male presented with a history of 3 stone weight loss (42 lbs to our US cousins, 19kg to the metric world) over a period of three months. He complained of malaise and was anaemic. Endoscopy of the upper gastrointestinal tract was normal.

A barium small bowel meal was performed.

Findings

Changes of early/intermediate Crohn's disease, with thickened folds, tending to asymmetry and obliteration in places. There are small apthous ulcers, and nodules, with normal diameter bowel. There is a linear mesenteric ulcer (arrowed, lower image).

Diagnosis

Small bowel Crohn's disease

Discussion

Early disease

Radiology and Pathology correlate well.

1. Thickened folds - Generally regular and more symmetrical than intermediate Crohn's. Produced by hyperplasia of lymphoid tissue and obstructive lymphoedema in submucosa.
2. Thickened villi - Adhere to one another producing a coarse villous pattern (granular/lumpy mucosal surface).
3. Apthoid ulcers - Produced by hyperplasia of lymph follicles in lamina propria and overlying shallow mucosal erosions 1 - 3mm.
4. Affected villi produce increased mucous secretions.

Above features are non-specific for Crohn's but, if 2 or 3 of the above are present, then Crohn's should be suspected. Above features are best seen with enteroclysis.

Intermediate disease

1. Widening of base of folds to cause partial or total disappearance secondary to increasing submucosal oedema. This process mimics thumbprinting seen in ischaemia.
2. Development of distorted folds - Secondary to fibrosis. Shortening on mesenteric border in particular.
3. Deepening of ulcers - Enlarged, rose thorn shape.
4. Typical linear ulcer on mesenteric border separated from adjacent submucosa by oedema.
5. Inflammatory polyps - Nodular pattern. Polyps more common in colonic disease. Usually found in area denuded of folds. In profile, polyps appear as "notches" into barium. Diameter of bowel is not reduced - differentiate from ulceronodular "cobblestone" pattern of advanced disease.

Intermediate disease changes are more obviously asymmetrical with skip areas.

Advanced disease

Transmural disease reaches serosa and beyond.

1. Ulcers - deep linear clefts and fissures. Islands of surviving mucosa produce pseudopolyp "cobblestone" appearance. This pattern is always associated with lumen reduction. Large flat ulcers - derived from enlargement of apthoid ulcers.
2. Linear mesenteric ulceration extends caudad. Antimesenteric redundancy and "pleating" disappears as disease extends transaxially around bowel lumen.
3. Thickened bowel wall - (now seen on CT with inflammatory changes extending into mesentery). Thickening secondary to fibrosis.
4. Complications:
   1. Strictures.
   2. Abscesses.
   3. Fistulas.
   4. Perforation.
   5. Carcinoma - Increased incidence with small bowel disease. Affects younger patients. Distal ileum (76%) usually in areas of long standing disease. Very difficult to diagnose pre-operatively.

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