Journal of the Formosan Medical Association (2013) 112, 652e653 Available online at www.sciencedirect.com ScienceDirect journal homepage: www.jfma-online.com CORRESPONDENCE Ileal Crohn’s disease with perforation misdiagnosed as ruptured appendicitis: A case report Wei-Fan Hsu a, Chien-Sheng Wu b, Jiann-Ming Wu c, Chen-Shuan Chung a,* a Division of Gastroenterology and Hepatology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan b Division of Rheumatology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan c Department of Surgery, Far Eastern Memorial Hospital, New Taipei City, Taiwan Received 2 July 2013; received in revised form 6 July 2013; accepted 9 July 2013 Crohn’s disease (CD) is a chronic transmural inflammation of any part of the alimentary tract, especially the distal ileum and the proximal large bowel. CD is diagnosed through history, diagnostic images, and pathological findings.1 The differential diagnoses of CD are numerous, and they include inflammatory, neoplastic, and infectious disease.1,2 Owing to protean presentations of CD, CD could be misdiagnosed as appendicitis. A 19-year-old male presented to a tertiary hospital with dull abdominal pain and rebound tenderness in the right lower quadrant (RLQ) area. He had watery diarrhea and weight loss of approximately 10 kg for 2 months. Computed tomography of the abdomen showed an enlarged appendix and mural enhancement of the terminal ileum (Fig. 1A). Laparoscopic appendectomy was performed because of presumptively ruptured appendicitis. After the appendectomy, the patient had recurrent spiking fevers and bloody stools for 15 days; therefore, he was transferred to our hospital. Pale conjunctivae and abdominal tenderness in the RLQ region, without peritoneal signs, were observed. Owing to persistent * Corresponding author. No. 21, Section 2, Nan-Ya South Road, Banciao District, New Taipei City, Taiwan. E-mail address: [email protected] (C.-S. Chung). bloody stools and inconclusive diagnosis of bleeding after angiography, intraoperative enteroscopy was performed antegradely from the proximal jejunum to the transverse colon; this showed several 5e20 mm deep discrete ulcers with scattered pseudopolyps from the distal jejunum to the whole ileum, sparing the proximal colon (Fig. 1B). Several sealed microperforations with abscesses and adhesion formation were observed at the distal small bowel. Ileocolectomy and intra-abdominal abscess drainage were performed. The pathological features included multiple discrete ileal ulcers, with the focal ulcer appearing as fissure-like transmural involvement (Fig. 1C). No evidence of mucin depletion, distorted crypt architecture, granuloma, vasculitis, or specific causative microorganisms was documented. The final diagnosis was ileal CD, with perforation complicated with an intra-abdominal abscess. The postoperative course was smooth, and the patient was discharged 11 days after the operation. Enteral prednisolone (20 mg/day) and mesalazine (3 g/day) were administered, and his clinical condition improved with endoscopic remission. Local peritonitis in the RLQ prior to appendectomy in this patient could be explained by microperforations with abscess and adhesion formation, and the clinical presentation may be mistaken as McBurney’s sign. However, watery 0929-6646/$ - see front matter Copyright ª 2013, Elsevier Taiwan LLC & Formosan Medical Association. All rights reserved. http://dx.doi.org/10.1016/j.jfma.2013.07.005 Ruptured CD misdiagnosed as ruptured appendicitis 653 Figure 1 (A) Computed tomography of the abdomen prior to an appendectomy shows mural enhancement of the terminal ileum (arrowhead); (B) the intraoperative enteroscopic image shows several 5e20 mm deep ulcers with scattered pseudopolyps from the distal jejunum to the whole ileum; (C) the pathological features include multiple discrete ileal ulcers, and focal ulcers appear as fissure-like transmural involvement (arrow). diarrhea and weight loss for 2 months were unlikely features of appendicitis. Also, mural enhancement of the terminal ileum prior to appendectomy was not a typical radiological finding of appendicitis. Therefore, an alternative diagnosis should have been considered. The relationship between appendectomy and CD is still debated. Kaplan et al3 showed a markedly increased risk of diagnosed CD within 6 months after an appendectomy and no risk of CD beyond 5 years after an appendectomy. The authors concluded that the transient increased incidence of CD after an appendectomy resulted from a diagnostic problem. It has been shown that CD patient numbers have markedly increased since 2004.4 Hence, physicians should consider this disease during a differential diagnosis for patients with such symptoms, especially when the prevalence of CD is increasing in the Asian population nowadays.5 The association between appendectomy and CD is still controversial, and pitfalls of differential diagnosis between them are of great concern. References 1. Feldman M, Friedman LS, Brandt LJ. Sleisenger and Fordtran’s gastrointestinal and liver disease: pathophysiology, diagnosis, management. 9th ed. Philadelphia: Saunders/Elsevier; 2010. 2. Hsu CH, Jeng YM, Ni YH. Clostridium difficile infection in a patient with Crohn disease. J Formos Med Assoc 2012;111: 347e9. 3. Kaplan GG, Pedersen BV, Andersson RE, Sands BE, Korzenik J, Frisch M. The risk of developing Crohn’s disease after an appendectomy: a population-based cohort study in Sweden and Denmark. Gut 2007;56:1387e92. 4. Wei SC, Ni YH, Yang HI, Su YN, Chang MC, Chang YT, et al. A hospital-based study of clinical and genetic features of Crohn’s disease. J Formos Med Assoc 2011;110: 600e6. 5. Prideaux L, Kamm MA, De Cruz PP, Chan FK, Ng SC. Inflammatory bowel disease in Asia: a systematic review. J Gastroenterol Hepatol 2012;27:1266e80.
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