LARGE BOWEL SYMPTOMS IN AN ELDERLY PATIENT

A 70 year old lady was referred to the surgical clinic 10 years ago with:

One year history of intermittent episodes of diarrhoea and malaise with associated colicky left iliac fossa pain and occasional rectal discomfort
Normal bowel habit in between these episodes. She denied any rectal bleeding or mucus
1/2 stone weight loss over the last year

Past Medical History

On examination, she was tender in her left iliac fossa and her blood profile was normal apart from an elevated ESR.

Suggest a differential diagnosis for this lady based on the information given?
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Diverticular disease was considered to be the most likely cause for her symptoms and a barium enema was arranged. This revealed severe diverticular disease of the sigmoid colon.

What are the treatment options?
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On review at clinic, her symptoms had settled and she was discharged from further follow up and advised to take a high fibre diet.

She was re-referred four years later with:

4 week history of severe crampy lower abdominal pain with urgency of defecation, passing soft stool each time but no blood or slime
Rigid sigmoidoscopy was normal
A repeat barium enema was unchanged in appearance, other than moderate spasm in the bowel. This was treated with an antispasmodic and her symptoms had settled on further review 8 weeks later.
Diverticular disease was considered the most likely explanation

 

 

Ongoing symptoms led to an anterior resection
for her severe diverticular disease, from which
she made a good recovery. The specimen
pathology report showed granulomas, but these
were not thought to be Crohn's disease.

 

 

 

She was recently referred with occasional bouts of abdominal pain since the anterior resection, but since undergoing a hip replacement (with antibiotic cover), she had almost "continuous diarrhoea" with severe left iliac fossa pain and weight loss. There was no blood in the bowel motions. Her stool culture was clear. She had a tender left iliac fossa on examination with a florid proctitis on sigmoidoscopy. Rectal biopsies were sent for histological examination. Her inflammatory markers were elevated (ESR 110, CRP 96.6)

 

What does this barium enema show?
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Rectal biopsies:

What features are seen?
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Non caseating giant cell granulomas are found in 60% of patients with Crohn's. They are most commonly seen in anorectal disease.

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Crohn's disease is a chronic inflammatory disease which can affect any part of the gastrointestinal tract. Ileocolonic disease is the most common. Ileal disease accounts for 60% of cases. In 30% of patients the disease is limited to the large intestine. It appears that large bowel Crohn's disease is increasing in frequency. It is slightly more common in females than males. Although it is most commonly diagnosed in young patients between the ages of 25 and 40, it can occur at any age and there appears to be a distinct increase in elderly patients in the 70-80 age group when it presents with abdominal pain and diarrhoea. Presentation can be acute or chronic. Acute Crohn's disease occurs in 5% of cases and can resemble acute appendicitis. Chronic Crohn's (as in this case) often presents with a history of mild diarrhoea extending over many months, coming in bouts and accompanied by colicky abdominal pain. Intermittent fevers, secondary anaemia and weight loss are common.

The mainstay of treatment is medical (steroids and 5 ASA compounds). Surgery is indicated for complications of the disease which include recurrent intestinal obstruction, bleeding, perforation, failure of medical management, intestinal fistula, fulminant colitis, malignant change, perianal disease.

How might the disease be investigated further in this patient?
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Almost certainly this patient had Crohn's disease during this 10 year period. As diverticular disease is extremely common in the Western world and most commonly presents in the sigmoid colon, it is relatively easy to miss other conditions limited to the sigmoid colon when a barium enema shows diverticular changes. At the time of the anterior resection, granulomas were seen on histological examination. At the time the pathologist did not believe this to be a case of Crohn's disease as other features were not present. Foreign body granulomas can occur in diverticular disease, probably due to the presence of faecal material in the submucosa causing this type of inflammatory reaction. The slow progress of the condition over 10 years, despite the patient receiving no medication, is typical of chronic inflammatory bowel disease. As the condition is limited to the rectosigmoid area, the prognosis is good.

Dr Stuart Robertson