On April 30, 2014, a 46-year-old male patient was admitted to the gastroenterology department with dyspepsia, abdominal pain, vomiting, and a 4 kg weight loss. The patient had previously undergone an appendectomy and abdominal abscess debridement for right abdominal pain and fever in January 2008. Seven months after the operation, he underwent a resection of the ileocecum for a spontaneous perforation that occurred in August 2008. The pathological diagnosis was ITB and the patient underwent antituberculosis therapy for 1 year.
The patient was hospitalized for right lower quarter pain on April 30, 2014. He had a fever, and physical examination revealed a bulge on the right lower abdomen, obvious tenderness, no fluctuation, no rebound pain, and muscle tonus. The laboratory results for the patient revealed the following: a white blood cell count of 11.77 x 109/L (normal range 4-11 x 109/L), thrombocytosis (platelet concentration of 469 x 109/L, normal range 100-300 x 109/L), and a fecal occult blood test of 1+. All other tests were normal. The computer tomography (CT) scans showed a segmental and irregular thickening of the anastomosis, ascending colon, and hepatic flexure with thickened mesenteric fat; dense shadows of anastomosis; and multiple stripes, nodes, exudation, and bubbles. Colonoscopy revealed a severe hyperemia and edema of mucosa in the anastomosis that was associated with inflammation, a fistulous opening, mucopurulent exudate, and multiple deep ulcers. The pathology showed mucosal chronic inflammation associated with ulcers and acute inflammation, moderate atypical hyperplasia of the glands, and a crypt abscess. The patient became asymptomatic after anti-inflammatory and nutritional support therapy.
The patient was hospitalized for right lower quarter pain again on June 15, 2014. His vital signs were normal and physical examination revealed a mass on the right lower abdomen (5 x 4 cm in size). All laboratory tests were normal. The CT scan showed the wall thickness of the right colon and the anastomosis, and the gas shadow in swelling soft tissue of the right lower abdominal wall (Figure 1). A right hemicolectomy was performed after the preparation because of the persistent right lower abdominal mass. Macroscopic histopathology showed that the intestinal wall was thickened with luminal narrowing (Figure 2).
The pathology after the operation showed colic mucosal ulceration along with transmural inflammation, mixed inflammatory infiltrate, and granuloma (ie, lymph cells and plasmacytes infiltrated the abdominal wall, and a granulomatous change occurred in the muscular layer) (Figure 3). The Ziehl-Neelson stain for acid-fast bacilli was negative. As the time between the first diagnosis and the second diagnosis was 6 years, 2 of our pathology experts rechecked the pathological data with the permission of the patient and the hospital. Both experts considered that the pathological diagnosis should be CD rather than ITB. Ultimately, we made a diagnosis of CD, which is indicative of the pathological changes and the history of recurrent intestinal fistula. According to the patient's CDAI, he was treated with infliximab. At the time of the 8-month follow-up, the patient had remained in complete remission and made a good recovery.