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eDoctor In
Apr 03, 2021
In Case Discussions
• 12 Years old girl underwent open appendectomy for appendicular perforation on 25-may-2020. • She was apparently asymptomatic till June 2020 when she followed up with complaints of opening up of previous incision wound with pus discharge. • She was treated conservatively with antibiotics according to pus culture sensitivity report . • Since then her wound hasn’t healed and she is having persistent discharge. Wound dehiscence in June 2020. • She was evaluated in December 2020. • Colonoscopy was done – showed ulceration with nodularity of IC junction , with narrowing ulceration at IC junction. Scope couldn't be passed into terminal ileum. • Biopsy slides were reviewed here. • IC biopsy- suggestive of mild active inflammation. Mild cryptitis, no evidence of parasites , granulomas, dysplasias, malignancy. • Gene Xpert and Rapid TB culture done on colonoscopic biopsy, did not show any M. Tb growth. • Appendectomy slide review- suggestive of granulomatous appendicitis. No necrosis was seen. MR enterogram (December 2020) • Contracted and deformed Cecum with adjacent mural thickening ectending into the terminal ileum. • Significant luminal narrowing with evidence of enterocutaneous fistula opening into right iliac fossa lateral wall. • Puckering of the overlying skin suggestive of chronic fistula. • Few subcentric lymphnodes noted in the RIF. MR enterogram (December 2020) • Came to AIG for further evaluation. • Only symptoms – occasional pain in abdomen on/off, crampy in nature and perisistent discharge from the wound. • Routine investigations were done. • Mountoux test done in January 2020 was negative. • TB quantiferon gold done on January 2020 was negative. • LFT, RFT, were unremarkable. • Hb- 11gm/dl , serum iron – 35mcg/dl. • ESR – 28mm/hr. • Fecal calprotectin – 75mg/kg. Present status of wound and discharge. Summary • 12 years old girl, • Status post appendectomy on may 2020, • Persistent enterocutaneous fistula since June 2020. • Next plan of management ??
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eDoctor In
Mar 19, 2021
In Case Discussions
Nov 2019 • Large volume watery loose stools (10-12 episodes) (nocturnal) with occasional drops of blood, tenesmus and urgency • No associated pain abdomen, borborygmi, fever or vomiting • UGIE- normal • CT enterography- normal • Sigmoidoscopy- diffuse loss of vascular pattern with erythema and multiple superficial ulcers in rectum and sigmoid • HPE- moderately dense infiltrates of plasma cells, lymphocytes and neutrophilic focal cryptitis, crypt abscessesà Early IBD • Steroids and Mesalamine Feb 2020 • Peri umbilical colicky pain abdomen with distension à better with vomiting (non bilious) or stool passage • AZT intolerance (TPMT positive) • F. calprotectin 128 • CMV IgM and DNA PCR- negative • ANA, anti ds DNA, ASMA, anti LKM1 negative • Anti tTG negative • Ileo colonoscopy and CT enterography- normal • Random biopsies- chronic active infl- consistent with UC till TI June 2020 • UGIE- nodularity and scalloping in D2 • HPE- focal flattening of epithelium with intraepithelial neutrophilic infiltration; cryptitis, crypt abscess, crypt loss, dense lymphoplasmacytic infiltration in lamina propria, basal plasmacytosis; no granuloma/ dysplasia/ malignancy • Ileocolonoscopy- normal • Random HPE- chronic ileitis with activity, crypt loss, increased IELs, chronic proximal predominant colitis with activityà ?Autoimmune enteritis/ IBD • Video capsule enteroscopy- diffuse loss of small intestinal folds and mucosal atrophyà ? Tropical sprue • MRCP- GB sludge; normal biliary tree • ANA profile negative • Steroids, Pentasa • Nitazoxanide, antibiotics On evaluation at AIG HOSPITALS • CBP normal (Hb 10.3; MCV 102) • B12- 1008; Vit D 9.2; Iron- 40 • ESR 7 • LFT normal except Albumin 2 • Anti tTG negative • OGD- D2 scalloping (HPE- mild villous atrophy without IELs) • Ileo colonoscopy- mucosal edema with patchy vascularity in recto- sigmoid (HPE- mild active infl) • USG abdomen and CT enterography- normal Ø 20 years girl on wheat and milk free diet Ø Large volume watery diarrhea- non bloody; lower abdominal pain with vomiting Ø D2 scalloping- no increase in IELs Ø Nonspecific recto sigmoid erythema Currently in ICU with hypotension Kindly share your comments?
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eDoctor In
Dec 09, 2020
In Case Discussions
No previously known comorbidities, presented elsewhere with loose stools large bowel type, 3-6 episodes per day associated with blood for initial 10 days, intermittent diffuse post prandial pain abdomen, abdominal distension, esayfatigability, loss of appetite and weight (16 kg) since past 2 months • On evaluation • Hb– 6.9, TLC – 8740, Plt 5lakhs • LFT – Normal Alb 3.4, TSH 1.89 • UGIE – Grade B esophagitis • Colonoscopy (15/9/20) diffuse involvement of mucosa with loss of vascularity, granularity, friability and diffuse ulcerations from rectum to mid transverse colon • Biopsy – Cryptitis, Crypt abscess with dense inflammatory infiltrate in lamina propria CECT Abd (13/10/20) • Diffuse edematous wall thickening of entire large bowel • Sub acute near complete thrombosis of SMV, thrombosis of left branch of PV, distal MPV and SMV, complete thrombosis of right hepatic vein, perfusion abnormalities in SegV of liver, no ascites • Managed with warfarin, diuretics, mesalamine, 2 units PRBC CECT Abd (27/10/20)circumferential mural thickening involving large bowel and rectum with mild adjacent fat stranding, thrombosis of left branch of PV, distal MPV and SMV, moderate ascites, bilateral minimal pleural effusion EVALUATION • CBP – Hb 9.1, MCV 90, TLC 4400, Plt – 1.2 lakhs • LFT/RFT – WNL except for severe Hypoalbuminemia (TP/Alb – 4.6/1.6) and Hypokalemia • Lactate – 0.9, LDH - 366 • 2D ECHO – Normal study • CECT Abdomen (21/11/20) – perfusion abnormalities in liver, diffuse mural thickening in proximal colon, transverse, descending colon and proximal sigmoid colon, thrombosis of MPV extending into left branch of PV and its tributaries, splenoprtalconfluence and proximal splenic vein, SMV showed partial recanalization, moderate ascites
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eDoctor In
Oct 03, 2020
In Case Discussions
- A 31 year old male with no known comorbidities - Abdominal pain-diffuse in nature along with abdominal distention, 3 episodes of non feculent vomiting as well low grade documented fever since 3 days - On examination-Distended abdomen with tenderness on the right hypochondrium area - Laboratory examination/ultrasound-unremarkable - In view of rapid onset symptoms patient underwent an Contrast enhanced CT alongwith inspection of the bowel with an colonoscope - Colonoscopy-Deformed Ceacum/IC valve with ulcerations(scope not passed beyond) - Biopsy – Active granulomatous colitis –Koch>CD - MTB –PCR –Positive - CT Imaging-Edematous thickened ileal loops with focal air pockets noted 30 cm from the terminal ileum -? Pneumoperitonium - In view of continued symptoms and possibility of pneumoperitonium the patient underwent an emergency laparotomy with segmental resection and double barrel stroma - Post op-unremarkable - Patient was discharged on day 8 post op with ATT (HRZE) - Post Surgical specimen – focal ulceration, necrosis, granulation tissue with no evidence of Granulomas/IBD
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eDoctor In
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