INTESTINAL OBSTRUCTION BY GIANT INFLAMMATORY POLYPOSIS IN A PATIENT WITH ILEO-COLONIC CROHN’S DISEASE

Mircea Mănuc, Cătălin Vasilescu, Vlad Herlea, Mona Dumbravă, Teodora Mănuc, Larisa Badea, Cristian Gheorghe
Fundeni Clinical Institute

We present the case of a 23-year-old male patient previously diagnosed with pediatric ileo-colonic Crohn’s disease (Montreal A1 L3 B1), who is hospitalized urgently with subocclusive syndrome preceded by intermittent bloody diarrhea (3-4 stools per day half-tied) , which led to a limitation of diet and weight loss of 10 kg in the last 3 months.

From the history we remember that the diagnosis was established at the age of 16 and the evolution was chronic recurrent, with multiple moderate-severe outbreaks treated with corticosteroids, being considered corticodependent.

The patient was first evaluated at our center a month ago when a colonoscopy was performed that found: – distal rectum and sigmoid without lesions, – all other colon segments with rare areas of quasi-normal mucosa, alternating with areas with hyperemia, vascular pattern diminished, and multiple polypoid formations of varying sizes and shapes, from 3 to 30 mm, some conglomerate, with surface erosion, forming true “clusters” that occupied more than 2/3 of the colonic lumen, but which allowed the colonoscope to progress (Photo PHOTO 1 – transverse colon – multiple pseudopolyps of various sizes and shapes that “wallpaper” the mucosa, the polyp being biopsied with a “longfinger-like” appearance, with ulcerated elevated areas on the surface PHOTO 2 – descending colon – multiple pseudopolyps of various sizes and shapes, a giant pseudopolyp shows on the surface inflammation and multiple exulcerations (biopsy) PHOTO3 – sigmoid-proximal colon visualizes the mucosa without pseudo-polyps, In the central area, small pseudopolyps are observed, and in the distance, a giant pseudopolyp is observed. PHOTO4 – transverse colon – there is a giant pseudopolyp developed “in clusters” in the colonic lumen with a quasi-obstructive appearance (minimal local bleeding after biopsy) in its periphery are identified small pseudopolyps.). The terminal ileum was normally 5 cm.

Multiple biopsies were taken and the histopathological examination was typical for the diagnosis of inflammatory bowel disease with histological activity, respectively inflammatory colonic polyps (inflammatory pseudopolyps), with areas of exulceration and erosions (Photo 5-6. PHOTO5 – Colonic mucosa showing focal disorganized glandular architecture (some branched, shortened glands) with mixed inflammation, slightly increased chorionic density, active focal, non-granulomatous (HE100x) PHOTO6-Biopsy fragment from a colonic polyp with marked mucosa (branched glands, of unequal caliber, numerically reduced) with diffuse polymorphic inflammation in the chorion, erosive, with superficial granulation tissue, without lesions of epithelial dysplasia – aspect of inflammatory colonic polyp (HE, 100x)). At that time, the opportunity for surgery was discussed, but the patient delayed it.
At the current clinical examination, the patient is cachectic BMI 15.4 (G = 50 kg, H = 180 cm), with pale skin, dehydrated, afebrile, cardio-respiratory balanced, with a relaxed abdomen, diffuse tympanic membrane with a palpable formation in mesogastric, sensitive to palpation, without defense or contracture.
Biologically we notice hypoalbuminemia (albumin 2.4 g / dl), iron deficiency anemia (Hb 9.8 g / dl) and significant inflammatory syndrome (leukocytosis with neutrophilia (15.6 x 10 * 3), CRP 175mg / l, fibrinogen 740 mg / dl). The infectious balance on admission was negative.

Contrast abdominal-pelvic CT examination reveals multiple polypoid lesions from the distal ascending colon to the descending colon. The most important lesions are in the transverse colon, which occupies almost all of them, with a maximum diameter of 42 mm, but without dilatation upstream, with parietal parietal thickening and significant loco-regional inflammatory changes, with multiple small indistinguishable abscesses of liver flexure. colonic and proximal transverse colon, with uncertain membership, colonic or pericolonial subserous intraparietal and minimal ascites.

After the multidisciplinary discussion, it is decided for surgery in the context of the presence of complications (obstruction, intraparietal abscesses), considering also the impossibility of differentiating from a possible neoplasia developed during inflammatory bowel disease.
Subtotal colectomy with terminal ileostomy is performed. Histopathological examination reconfirmed the diagnosis of colonic Crohn’s disease and inflammatory bowel pseudopolyposis, with no evidence of dysplastic or neoplastic lesions (Photo 7-10. PHOTO 7-Colonial mucosal areas with moderately disorganized glandular architecture and chronic active inflammation in the chorion, HE PHOTO 8-Chronic active inflammation in the colonic mucosa, with frequent cryptitis and cryptic microabscesses (HE, 100x) PHOTO 9-Chronic inflammatory infiltrate tr