67-year-old male presenting with a 6-month history of right lower quadrant abdominal pain, diarrhea (4-6 watery stools/day, occasionally bloody), 10 lb weight loss, and fatigue. Symptoms worsened over the past month, with episodes of postprandial pain and nocturnal diarrhea. Former smoker with a 20-pack-year history, quit 10 years ago. No prior history of IBD. Positive for low-grade fever.
A 67-year-old male presents with a 6-month history of diarrhea and weight loss. An SBFT with a focus on the RLQ and terminal ileum shows irregular mucosa, lack of organized valvulae conniventes, strictures, and skip lesions, consistent with the segmental involvement characteristic of Crohn’s disease. The colon appears normal. Differential diagnosis includes infectious enteritis and ischemic enteritis.
Ashley Davidoff MD TheCommonVein.net 139824 (003SB).
A 67-year-old male presents with a 6-month history of diarrhea and weight loss. An SBFT with a focus on the RLQ and terminal ileum shows irregular mucosa, lack of organized valvulae conniventes, strictures, skip lesions, and a pseudodiverticulum, consistent with the segmental involvement characteristic of Crohn’s disease. The colon appears normal. Differential diagnosis includes infectious enteritis and ischemic enteritis.
Ashley Davidoff MD TheCommonVein.net 139825 (003SB).
A 67-year-old male presents with a 6-month history of diarrhea and weight loss. An SBFT with a focus on the RLQ and terminal ileum (magnified in b – red asterisks) and shows diffuse irregular narrowing, irregular mucosa, (maroon arrowheads) lack of organized valvulae conniventes, strictures, (yellow arrowheads) and a pseudodiverticulum (green arrowhead), with mild upstream dilatation of the normal bowel (pink asterisk). The constellation of findings are characteristic and consistent with Crohn’s ileitis. Differential diagnosis includes infectious enteritis and ischemic enteritis as less likely possibilities.
Ashley Davidoff MD TheCommonVein.net 139825 (003SB).
A 67-year-old male presents with a 6-month history of diarrhea and weight loss and a one month history of worsening symptoms.
A CT scan in the axial projection in the deep pelvis (magnified in b) shows diffuse wall thickening and luminal narrowing, irregularity of the mucosa and 2 focal regions of more significant narrowing with mild upstream dilatation of the normal ileum. There is mild congestion and induration of the subtending mesentery suggesting creeping fat. The visualised portion of the ascending colon contains liquified stool and has otherwise normal appearance. The constellation of findings are characteristic and consistent with acute Crohn’s ileitis. Differential diagnosis includes infectious enteritis and ischemic enteritis as less likely possibilities.
Ashley Davidoff MD TheCommonVein.net 139832c (003SB).
A 67-year-old male presents with a 6-month history of diarrhea and weight loss and a one month history of worsening symptoms.
A CT scan in the axial projection in the deep pelvis (magnified in b) shows diffuse wall thickening and luminal narrowing (red asterisk), irregularity of the mucosa (maroon arrowheads) and 2 focal regions of more significant narrowing (yellow arrowheads), with mild upstream dilatation of the normal ileum (pink asterisk). There is mild congestion and induration of the subtending mesentery (enclosed in white loop) suggesting creeping fat. The visualised portion of the ascending colon contains liquified stool and has otherwise normal appearance (white asterisk). The constellation of findings are characteristic and consistent with acute Crohn’s ileitis. Differential diagnosis includes infectious enteritis and ischemic enteritis as less likely possibilities.
Ashley Davidoff MD TheCommonVein.net 139832cL (003SB).
A 67-year-old male presents with a 6-month history of diarrhea and weight loss and a one month history of worsening symptoms. A CT scan in the coronal plane, with a focus on the pelvis (magnified in b), shows thickened loops of small bowel. The loop in the RLQ exhibits a thick wall with a narrowed lumen and alternating layers of enhanced and relatively non-enhanced wall. These stratifications are also appreciated as a “target sign” in the small bowel loop in the LLQ, which causes mass effect on the bladder. The loop abutting the left pelvic wall shows mild dilatation and dilution of contrast. Evidence of creeping fat in the mesentery subtending the affected loops is characterized by vascular and lymphatic congestion and mild induration. There is a small focus of loculated fluid along the right iliac vessels.
These findings are almost pathognomonic of acute Crohn’s ileitis. Included in the differential diagnosis, though less likely, are infectious enteritis and ischemic enteritis.
Ashley Davidoff MD TheCommonVein.net 139827c (003SB).
A 67-year-old male presents with a 6-month history of diarrhea and weight loss and a one month history of worsening symptoms. . A CT scan in the coronal plane, with a focus on the pelvis (magnified in b), shows thickened loops of small bowel. The loop in the RLQ exhibits a thick wall with a narrowed lumen and alternating layers of enhanced and relatively non-enhanced wall (yellow arrowhead) . These stratifications are also appreciated as a “target sign” in the small bowel loop in the LLQ, which causes mass effect on the bladder (red arrowhead) . The loop abutting the left pelvic wall shows mild dilatation and dilution of contrast (pink arrowhead). Evidence of creeping fat in the mesentery subtending the affected loops is characterized by vascular and lymphatic congestion and mild induration (enclosed in white ring). There is a small focus of loculated fluid along the right iliac vessels (teal arrowhead).
These findings are pathognomonic of acute Crohn’s ileitis. Included in the differential diagnosis, though less likely, are infectious enteritis and ischemic enteritis.
Ashley Davidoff MD TheCommonVein.net 139827cL (003SB).
The implications of acute Crohn’s ileitis in a 67-year-old patient presenting with the target sign, creeping fat, strictures, and diffuse narrowing of the mucosa are significant and multifaceted.
1. Target Sign: This radiologic finding indicates active transmural inflammation, which is a hallmark of Crohn’s disease. It suggests severe disease activity and the potential for complications such as fistulas and abscesses.[1]
2. Creeping Fat: The presence of creeping fat is associated with a more complicated disease course. It is linked to bowel damage, strictures, and an increased likelihood of requiring surgical intervention. Creeping fat is also associated with increased mesenteric inflammation and fibrosis, contributing to stricture formation.[2-3]
3. Strictures: Strictures in Crohn’s disease can lead to bowel obstruction, which is a common complication requiring surgical intervention. The presence of strictures, especially if they are long (>5 cm) or associated with significant bowel wall thickening (≥10 mm), increases the risk of surgery.[1][4]
4. Diffuse Narrowing of the Mucosa: This finding indicates chronic inflammation and fibrosis, which can lead to a reduced lumen diameter and potential for obstruction. It also suggests a chronic, progressive disease course that may not respond well to medical therapy alone and may necessitate surgical management.[5]
Given these findings, the patient is at high risk for disease-related complications, including bowel obstruction and the need for surgical intervention. The American Gastroenterological Association recommends close monitoring and potentially escalating medical therapy, including the use of biologics such as anti-TNF agents, which have been shown to reduce the risk of surgery in patients with strictures.[5] Additionally, surgical consultation may be warranted to evaluate the need for resection or other interventions to manage strictures and prevent further complications.[6]
Treatment Options:
1. Medical Therapy: The AGA recommends a cautious approach to immunosuppressive therapy in elderly patients due to the increased risk of infections and malignancies. While the efficacy of biologics and immunomodulators is similar to younger patients, the safety profile is a concern. Therefore, therapy should be individualized, considering the patient’s overall fitness and frailty. Low bioavailability steroids may be preferred initially to manage acute inflammation.
2. Biologics: Anti-TNF agents can be effective but are associated with higher rates of severe infections and malignancies in elderly patients. The decision to use biologics should involve a thorough risk-benefit analysis, and close monitoring is essential.
3. Surgery: Surgical intervention may be necessary for managing strictures and complications. However, elderly patients have higher postoperative complication rates, including infections and thromboembolic events. Early surgical consultation and careful preoperative assessment are crucial.
In summary, age necessitates a more cautious and individualized approach to the treatment of Crohn’s disease in elderly patients, balancing efficacy with the increased risk of adverse events.
References
- Magnetic Resonance Enterography for Predicting the Clinical Course of Crohn’s Disease Strictures. Schulberg JD, Wright EK, Holt BA, et al. Journal of Gastroenterology and Hepatology.
2.Creeping Fat Assessed by Small Bowel MRI Is Linked to Bowel Damage and Abdominal Surgery in Crohn’s Disease. Althoff P, Schmiegel W, Lang G, Nicolas V, Brechmann T. Digestive Diseases and Sciences. 2019;64(1):204-212.
3.The Mesenteric Fat and Intestinal Muscle Interface: Creeping Fat Influencing Stricture Formation in Crohn’s Disease. Mao R, Kurada S, Gordon IO, et al. Inflammatory Bowel Diseases. 2019;25(3):421-426.
Chaudhry NA, Riverso M, Grajo JR, et al. Inflammatory Bowel Diseases. 2017;23(4):641-649.
5.ACG Clinical Guideline: Management of Crohn’s Disease in Adults. Lichtenstein GR, Loftus EV, Isaacs KL, et al. The American Journal of Gastroenterology. 2018;113(4):481-517.
De Simone B, Davies J, Chouillard E, et al. World Journal of Emergency Surgery : WJES. 2021;16(1):23.