An Unusual Presentation of Crohn's Disease in an Elderly Patient: A Report of a Rare Case

Crohn's disease is a chronic inflammatory bowel disease that primarily affects the terminal ileum and proximal colon. The exact cause is unknown but likely involves genetic factors, environmental triggers, and immune dysregulation. This case report delineates the choice of diagnostics for a 70-year-old patient presenting with symptoms indicative of small bowel obstruction. Initial assessments and imaging suggested a common clinical scenario, yet further investigation uncovered an unexpected diagnosis of Crohn's disease, a condition infrequently encountered in this age demographic.

Perianal Mucinous Adenocarcinoma: A Case of Recurrent Anal Fistula

An anal fistula is a fairly common clinical condition, with a very low incidence of malignant transformation. Mucinous adenocarcinoma is a subtype of adenocarcinoma, and its occurrence within perianal fistula tracts is quite rare. This case report describes a 54-year-old male patient with recurrent anal fistula, initially suspected of Crohn's disease (CD), and ultimately diagnosed with perianal mucinous adenocarcinoma. After our joint internal medicine, surgery, and imaging reassessment, the diagnosis was confirmed. Anal fistula is usually considered a benign lesion, but it may also be associated with other diseases. Due to overlapping symptoms of related diseases, the investigation of malignant lesions is often overlooked. This case report emphasizes the importance of timely referral and multidisciplinary management for disease diagnosis and early treatment.

The Enigma of Crohn's Disease: A Case Report

Crohn's disease (CD) is an inflammatory condition affecting the gastrointestinal tract, often leading to persistent inflammation in various parts, notably the terminal ileum and colon. Clinical manifestations of CD can become complex due to complications like strictures, fistulas, and perianal abscesses. The disease typically exhibits transmural inflammation and skip lesions, where unaffected areas alternate with affected ones. Treatment goals focus on achieving disease remission and preventing complications that may require surgical intervention. Surgery becomes crucial in managing complications such as Crohn's strictures and perforations. Here, we describe a challenging case involving a young woman who underwent surgery for abdominal abscess and with Crohn's stricture and fistula.

Cutaneous Eruption in a Crohn's Disease Patient Under Tumor Necrosis Alpha Inhibitor Treatment: A Rare Case of Syphilis

Reaching a diagnosis of a cutaneous eruption in a Crohn's disease (CD) patient treated with anti-tumor necrosis factor alpha (anti-TNFα) can be challenging. Differential diagnosis must include extra-intestinal manifestations of CD, adverse reactions to the therapy itself as well as infectious diseases with cutaneous manifestations. We report the case of a 28-year-old man on infliximab for Crohn's colitis, who presented with painless, non-pruritic genital and body exanthema. After a thorough evaluation, early secondary syphilis was confirmed with a fluorescent treponemal antibodies-absorbed test. Intramuscular (IM) benzathine penicillin G 2.4 million units in a single dose was administered and clinical manifestations resolved completely within a couple of weeks.

Hidden in Plain Sight: A Case Series of Inflammatory Bowel Disease With Dermatologic Lesions As Initial or Concurrent Manifestations

Pyoderma gangrenosum (PG) and erythema nodosum (EN) are rare skin conditions associated with inflammatory bowel disease (IBD), with increasing incidence as the disease progresses. We describe three cases of newly diagnosed IBD with cutaneous extraintestinal manifestations (EIMs) at the time of diagnosis. Three previously healthy patients presented with bloody diarrhea and concomitant nodular and ulcerating skin lesions at the onset of diarrhea. Dermatopathology showed PG and EN with endoscopic confirmation of ulcerative colitis. Clinical improvement was achieved with steroids and biological agents. These cases display the importance of a proper review of symptoms and a detailed workup of dermatological lesions prior to assuming infectious etiology.

Prevalence and Impact of Obesity in a Population-Based Cohort of Patients With Crohn's Disease

BACKGROUND

Obesity is on the rise within the inflammatory bowel disease population. The impact obesity has on the natural history of Crohn's disease (CD) is not well-understood. We aimed to describe the prevalence of obesity in a population-based cohort of newly diagnosed patients with CD, and the impact obesity had on disease phenotype and outcomes of corticosteroid use, hospitalization, intestinal resection, and development of fistulizing or penetrating disease.

MATERIALS AND METHODS

A chart review was performed on Olmsted County, Minnesota residents diagnosed with CD between 1970 and 2010. Data were collected on demographics, body mass index, CD location and behavior, CD-related hospitalizations, corticosteroid use, and intestinal resection. The proportion of individuals considered obese at the time of CD diagnosis was evaluated over time, and CD-associated complications were assessed with Kaplan-Meier survival analysis.

RESULTS

We identified 334 individuals diagnosed with CD between 1970 and 2010, of whom 156 (46.7%) were either overweight (27.8%) or obese (18.9%) at the time of diagnosis. The proportion of patients considered obese at the time of their diagnosis of CD increased 2-3 fold over the course of the study period. However, obesity did not have a significant impact on the future risk of corticosteroid use, hospitalization, intestinal resection, or development of penetrating and stricturing complications.

CONCLUSIONS

Obesity is on the rise in patients with CD, although in this cohort, there did not appear to be any negative association with future CD-related outcomes. Further prospective studies, ideally including obesity measures such as visceral adipose tissue assessment, are warranted to understand the implications of the rising prevalence of obesity on CD outcomes.

Chilaiditi's Syndrome Mimicking Crohn's

Chilaiditi's sign (colonic interposition) is a rare anomaly due to an abnormally located portion of the colon that is interposed in between the liver and the diaphragm. This rare anomaly is often incidentally seen on chest or abdominal radiographs. Chilaiditi's radiographic sign is usually asymptomatic, whereas the medical condition accompanied by clinical symptoms is termed Chilaiditi's syndrome. Possible causes of the syndrome include a long and mobile colon, scarring of the liver (cirrhosis), ascites, long-standing lung disease, as well as laxity of the falciform ligament. The most common clinical signs of Chilaiditi's syndrome include gastrointestinal symptoms; however, clinical presentation can vary. This report describes a case of a 21-year-old male patient who presented with a longstanding history of left upper quadrant epigastric abdominal pain with diarrhea (six to eight loose watery stools). The patient was diagnosed with Crohn's colitis and had tried a myriad of medical therapies with no adequate response. He chose to seek a second opinion and was subsequently discovered to have Chilaiditi's syndrome via computed tomography (CT) and confirmed by barium enema. The patient then elected to undergo a right laparoscopic colectomy to resolve the symptoms. By postoperative day five, all symptoms had resolved including abdominal pain and diarrhea. Therefore, it is important to consider Chilaiditi's syndrome as a differential diagnosis in persons presenting with left upper quadrant pain and symptoms of Crohn's colitis, especially those treated with adequate medical therapy without alleviation of symptoms.

Granulomas Galore: Concomitant Granulomatous Infections in a Patient With Crohn's Disease

Tumor necrosis factor (TNF)-alpha inhibitors are effective biologics in the treatment of inflammatory bowel disease; however, they increase susceptibility to opportunistic infections. We report a case of a 74-year-old female with Crohn's disease who developed concomitant pulmonary tuberculosis (Mycobacterium tuberculosis [MTB]) and Histoplasmosis capsulatum infection while on adalimumab. Co-infection is rare in patients on TNF-alpha inhibitor therapy, and most cases have been reported in patients with human immunodeficiency virus (HIV). This was a challenging case for diagnosis and treatment due to indistinguishable presenting symptoms of both infections, similar laboratory and radiographical findings, and a clinical course complicated by drug-drug interactions and worsening of symptoms despite therapy.

Pneumatosis Intestinalis Manifesting as an Atypical Presentation of Crohn's Disease

Crohn's disease is an inflammatory bowel disease that has a bimodal distribution, occurring most frequently between ages 15 to 30 years and 40 to 60 years. It presents with a relapsing and remitting course. The most common area involved is the terminal ileum and right colon and the inflammation oftentimes leads to non-caseating granulomas and ulcerations in both the superficial mucosa and deeper layers. Additionally, pneumatosis intestinalis is defined as the presence of gas and free air in the extraluminal space of the intestines which is an abnormal occurrence and correlates with underlying pathology. There are only a few cases reported in the literature that present pneumatosis intestinalis in the setting of, and possibly linked to, Crohn's disease. Our case presents an elderly male patient with jejunal ulcerations and strictures suggesting Crohn's disease and associated pneumatosis intestinalis as evidenced on outpatient computed tomography (CT) enterography. Upon presentation to the hospital, the patient was non-toxic and was not complaining of any pain. During his inpatient stay, there was a suspicion of Crohn's disease and therefore he was started on Infliximab therapy. We will review the possible pathogenesis of Crohn's disease and other cases presenting pneumatosis intestinalis in the setting of Crohn's disease.

Treating Deep Venous Thrombosis in a Background of Crohn's Disease: A Clinical Conundrum

Deep venous thrombosis (DVT) commonly affects the lower extremities, often as a result of prolonged immobilization. However, upper limb DVT is an atypical presentation, typically associated with risk factors such as the use of a peripherally inserted central catheter (PICC) line. This case report describes an uncommon case of DVT management in a patient with Crohn's disease, a condition more frequently characterized by painful lower gastrointestinal symptoms and chronic diarrhea. A 22-year-old male with a history of Crohn's disease developed swelling and purplish discoloration at the brachial site of a PICC line site. Laboratory results indicated anemia with a hemoglobin level of 9.9 g/dL and a hematocrit of 31.9%. Doppler ultrasound confirmed the DVT in the left long axillary, left subclavian, and left long basilic veins. Given the patient's concurrent lower gastrointestinal bleeding, a cautious approach was required to balance the risks and benefits of anticoagulation. Upon recommendation by Hematology, a prophylactic dose of enoxaparin was initiated and subsequently escalated to a therapeutic dose as tolerated. The patient's condition was closely monitored, and he successfully reached the full therapeutic regimen without complications. This case underscores the importance of individualized DVT treatment strategies in the context of concurrent Crohn's disease, offering insights into managing anticoagulation in the presence of bleeding risks.

Dental Infection Causing Methicillin-Resistant Staphylococcus aureus Bacteremia and Spinal Infection: A Case Report

Poor dentition as a source of infection causing bacteremia and spinal infections (such as paraspinal abscess, and discitis) should be considered even in the absence of recent dental surgery. The case presents a patient found to have an infection in the cervical and thoracic spine, methicillin-resistant Staphylococcus aureus bacteremia, and poor dentition. Although the patient had a history of drug use, he denied a history of intravenous drug use. He had Crohn's disease that resulted in periodontal and endodontal tooth disease. The patient was found to have poor dentition with erythematous gums. He had not been to the dentist in over 24 years and had active dental caries. Since he presented with bacteremia and a spinal infection, it is likely the patient had an infection in the oral cavity that spread hematogenously to the blood, and then the spine. This report highlights the importance of considering tooth infections as the source of bacteremia and spinal infections.

Drug-Induced Hidradenitis Suppurativa: A Case Report

Hidradenitis suppurativa (HS) is a chronic, debilitating inflammatory disorder of the hair follicles that localizes to the intertriginous and anogenital regions of the body. Lesions are characterized by inflammatory nodules, subcutaneous abscesses, fibrosis, and sinus tracts. Crohn's disease (CD) is an idiopathic chronic inflammatory bowel disease that affects any part of the gastrointestinal tract. Multiple treatment options exist for CD, including monoclonal anti-tumor necrosis factor alpha (TNF-α) antibodies like adalimumab (Humira). Adalimumab is an anti-TNF agent that has been approved by the United States Food and Drug Administration (FDA) for the treatment of HS. A 35-year-old African American male with a history of fistulizing CD presented to the hospital for evaluation of severe pain and purulent drainage from open sores in his bilateral axillary regions, groin, buttocks, and face for four days. He was on adalimumab for two years, during which time he noted the development of Hurley stage III HS. The physical exam was remarkable for a cachectic, painful-appearing male, with multiple abscesses on his lower jaw extending to his upper neck draining thick serosanguinous fluid, with similar findings in his bilateral axillary regions, bilateral groin, and perianal regions. He was treated with intravenous antibiotics consisting of a fourth-generation cephalosporin and vancomycin. While the etiology of HS in this patient is inconclusive, the timing of its development closely aligns with the initiation of Humira and is not a manifestation of CD. Paradoxical adverse effects describe a phenomenon in which a medication can induce a condition that it classically can be used to treat. In this patient's case, it was HS.

Reliability and Usefulness of ChatGPT for Inflammatory Bowel Diseases: An Analysis for Patients and Healthcare Professionals

AIM

We aimed to evaluate the performance of Chat Generative Pre-trained Transformer (ChatGPT) within the context of inflammatory bowel disease (IBD), which is expected to become an increasingly significant health issue in the future. In addition, the objective of the study was to assess whether ChatGPT serves as a reliable and useful resource for both patients and healthcare professionals.

METHODS

For this study, 20 specific questions were identified for the two main components of IBD, which are Crohn's disease (CD) and ulcerative colitis (UC). The questions were divided into two sets: one set contained questions directed at healthcare professionals while the second set contained questions directed toward patients. The responses were evaluated with seven-point Likert-type reliability and usefulness scales.

RESULTS

The distribution of the reliability and utility scores was calculated into four groups (two diseases and two question sources) by averaging the mean scores from both raters. The highest scores in both reliability and usefulness were obtained from professional sources (5.00± 1.21 and 5.15±1.08, respectively). The ranking in terms of reliability and usefulness, respectively, was as follows: CD questions (4.70±1.26 and 4.75±1.06) and UC questions (4.40±1.21 and 4.55±1.31). The reliability scores of the answers for the professionals were significantly higher than those for the patients (both raters, p=0.032).  Conclusion: Despite its capacity for reliability and usefulness in the context of IBD, ChatGPT still has some limitations and deficiencies. The correction of ChatGPT's deficiencies and its enhancement by developers with more detailed and up-to-date information could make it a significant source of information for both patients and medical professionals.

Nyctalopia and Xerophthalmia in a Patient With Crohn's Induced Vitamin A Deficiency

The vitamin A derivative, retinal, plays a pivotal role in scotopic and color vision. Although vitamin A deficiency (VAD) presents as a common cause of preventable blindness in areas with poor access to foods rich in vitamin A, it is uncommon in developed countries. We present a 56-year-old male with a history of Crohn's disease and pancreatitis who was referred to our ophthalmology office by optometry for severe dry eyes. He complained of a two-year history of constant blurred vision and nyctalopia. He stated that "images just appear dark." Examination demonstrated mildly decreased visual acuity with severe ocular surface disease and characteristic Bitot's spots in both eyes. Based on the patient's history and physical, a diagnosis of xerophthalmia in the setting of VAD was made. The patient was referred to his internist, he then underwent further evaluation and treatment with vitamin A intramuscular injections post-diagnosis.  This case illustrates the potential for VAD secondary to malabsorption from Crohn's disease and the importance of taking a full patient history so systemic causes of ophthalmic symptoms may be promptly identified and treated. VAD is extremely rare in the United States, however, patients at risk for VAD may benefit from regular vitamin A level checks and ophthalmologic evaluation.

Challenges in Managing Paediatric Crohn's Disease With Crohn's Disease Exclusion Diet (CDED): The First Single-Center Study in the United Arab Emirates

BACKGROUND

Inflammatory bowel disease has been increasing significantly. For that, many modalities of treatment have shown promising results including a special diet. In our study, we looked at Crohn's disease dietary management for induction and subsequently maintenance of treatment. The research question was how feasible was applying this approach and what difficulties the patients and their parents faced.

METHODOLOGY

We reviewed the electronic medical system. We had 32 paediatric patients who were diagnosed with Crohn's disease and used the special diet plan (Crohn's disease exclusion diet or exclusion enteral nutrition) to induce remission or maintenance. Then, we used a questionnaire to identify the difficulties they faced while using the special diet.

RESULTS AND DISCUSSION

We have found that the cohort had used the special diet for a variable duration. The majority of patients opted to start with Crohn's disease exclusion diet. The clinical response was inconsistent due to poor compliance. Only 57 % of the patients were able to bear with the dietary plan beyond 12 weeks. Patients reported the following factors which caused non-compliance: intolerance/difficulty to follow (40%), cost (19%), poor clinical response (19%), and others.

CONCLUSIONS

In managing Crohn's disease, a multidisciplinary approach, including dietary interventions, is crucial. However, adherence to specialized diets poses several challenges identified in this study based on patient feedback. Addressing barriers and prioritizing dietitians' role is essential for improved patient outcomes in inflammatory bowel disease management.

Inflammatory Bowel Sugar Disease: A Pause From New Pharmacological Agents and an Embrace of Natural Therapy

Inflammatory bowel diseases (IBDs), including Crohn's disease and ulcerative colitis, are immune-mediated chronic inflammatory diseases that target the gastrointestinal tract and other distant organs. The incidence of IBDs has been rising and is more prevailing in Western communities. The etiology has been vague, but different theories include environmental factors that elicit an uncontrolled immune response, which damages internal organs. Treatment of either Crohn's disease or ulcerative colitis has witnessed significant advances; however, pharmacological drugs' side effects limit their use. Research about microbiota and its influence on IBDs has gained fame, and multiple studies correlate microbiota diversity positively with IBD treatment. Many factors contribute to the microbiota's health, including different diets, antibiotics, prebiotics, probiotics, synbiotics, and postbiotics. Specific immune responses lie behind the pathogenesis of IBDs and microbiota dysbiosis, and different studies have postulated new ways to control this abnormal response. Physical activity, sun exposure, efficient sleep, intermittent fasting, and supplementation of probiotics and vitamins are natural ways that help modulate this immune response, do not cost money as IBD pharmacological drugs, and do not come with deleterious side effects that are sometimes more harmful than IBDs. Our article proposes a comprehensive natural approach that can benefit IBD patients enormously. This approach does not replace the medications currently used in treating IBDs. The suggested approach can be used in combination with medications and might aid in reducing the doses of those medications.

Crohn's Disease is a Greater Risk Factor for Nonalcoholic Fatty Liver Disease Compared to Ulcerative Colitis: A Systematic Review

Crohn's disease (CD) and ulcerative colitis (UC) are inflammatory bowel diseases that have been associated with nonalcoholic fatty liver disease (NAFLD). This systematic review aimed to examine whether Crohn's disease confers a greater risk for nonalcoholic fatty liver disease compared to ulcerative colitis. A comprehensive search of electronic databases from January 2000 to May 2023 was conducted to identify observational studies investigating the association between Crohn's disease or ulcerative colitis and nonalcoholic fatty liver disease. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) 2020 checklist ensured transparent reporting, and the Newcastle-Ottawa Scale was used to assess study quality. Data synthesis revealed higher nonalcoholic fatty liver disease prevalence among Crohn's disease patients compared to ulcerative colitis patients across regions. Ten studies published between 2016 and 2022, encompassing a total of 4164 participants from three continents, were included in the review. The median proportion of Crohn's disease patients with nonalcoholic fatty liver disease was 37.22% (range: 10.95-53.80%), while it was 27.55% (range: 8.60-46.20%) for ulcerative colitis patients. Subgroup analysis by region confirmed CD's higher NAFLD risk. Median proportions for CD patients who developed NAFLD from North America, Europe, and Asia were 25.97% (range: 14.6-37.33%), 47.01% (range: 14.2-53.8%), and 20.78% (range: 10.95-30.6%), respectively, and the median proportion of persons with UC who developed NAFLD in studies from North America, Europe, and Asia were 17.28% (range: 8.6-25.96%), 37.70% (range: 25.64-46.20%), and 19.52% (range: 10.14-28.90%), respectively. Variations suggest differing mechanisms, disease features, and therapeutics. Transmural inflammation in Crohn's disease may increase metabolic abnormalities, including nonalcoholic fatty liver disease. Geographic differences in lifestyle, genetics, and environmental variables may also contribute. This review demonstrates that Crohn's disease patients face a higher nonalcoholic fatty liver disease risk than ulcerative colitis patients, emphasizing the need for early monitoring and prevention. Further studies are warranted to understand mechanisms and develop tailored management approaches.

Advancements in Inflammatory Bowel Disease: A Narrative Review of Diagnostics, Management, Epidemiology, Prevalence, Patient Outcomes, Quality of Life, and Clinical Presentation

Inflammatory bowel disease (IBD), encompassing ulcerative colitis (UC) and Crohn's disease (CD), is a chronic, immune-mediated disorder that impacts the gastrointestinal tract. Significant advancements in the diagnosis and treatment of IBD have been made during the past few decades, improving patient outcomes. This narrative review aims to provide an overview of recent developments in the diagnosis and treatment of IBD. Both from an evaluative and therapeutic standpoint, the management of IBD has undergone significant change. The standard of treatment for treating UC and CD patients has changed due to several medical developments. These developments include amino-salicylates, immunosuppressants, biological agents, and new therapeutics. The review also addresses the difficulties in applying these developments in clinical practice. Globally, the prevalence of IBD is rising, with Asia among the regions with the highest rates. These environments provide particular difficulties, such as poor disease knowledge, a lack of diagnostic services, and infectious IBD mimics. These issues must be resolved to diagnose and manage IBD in these populations accurately. New imaging modalities and other improvements in diagnostic methods have increased the precision and early identification of IBD. To reduce problems and improve patient outcomes, healthcare professionals treating patients with IBD must work effectively as a team. An extensive summary of current developments in the diagnosis and treatment of IBD is given in this narrative review. It draws attention to the therapeutic possibilities, difficulties, and uncertainties of integrating these developments into clinical practice. By keeping up with these changes, healthcare practitioners can better care for patients with IBD and improve their quality of life.

Meckel's Diverticulum Charading as Crohn's Disease: A Single-Institution Case Series

Meckel's diverticulum is the most common gastrointestinal congenital anomaly and may present with lower gastrointestinal bleeding, abdominal pain, and nausea. Imaging and endoscopic findings can be similar to those of Crohn's disease, including transmural inflammation, stricturing, and superficial ulceration frequently in the distal ileum. Here, we present a case series of three patients who were initially diagnosed with Crohn's disease and ultimately found to have Meckel's diverticulum alone on final pathology. This single-institution case series, the largest in the literature, highlights the importance of maintaining a high index of suspicion for Meckel's diverticulum, especially in the absence of microscopic evidence of inflammatory bowel disease.

Identifying Visceral Kaposi Sarcoma (KS): A Responsibility to Avoid Anchoring on the Diagnosis of a Crohn's Flare

The initial evaluation of reported inflammatory bowel disease (IBD) should include an assessment for immunosuppression which can broaden the differential diagnosis to include opportunistic infection as well as other processes. Here we present an exceedingly rare case of a patient with a self-reported history of Crohn's disease presenting with frequent diarrhea presumed to be a Crohn's flare, however, after further workup was found to have extensive visceral Kaposi sarcoma (KS).

An Unusual Case of Haemophilus parainfluenzae Endocarditis in a Young Patient With Crohn's Disease

We present a rare case of infective endocarditis (IE) associated with Haemophilus parainfluenzae in a 40-year-old male patient with a history of Crohn's Disease (CD). A complete workup, including an echocardiogram and blood cultures, revealed mitral valve vegetation colonized by H. parainfluenzae. The patient was started on appropriate antibiotics with follow-up for outpatient surgery. This case discusses the potential for ectopic colonization of heart valves by H. parainfluenzae in patients with CD. The presence of this organism as the offending agent in this patient's case of IE shines a light on the pathogenesis of CD. Although uncommon, CD-associated bacterial seeding should be a differential when assessing young patients with IE.

Infective Endocarditis as a Complication of Crohn's Disease on Immunotherapy

A patient with a history of Crohn's disease on infliximab presented to the hospital with sepsis and a new heart murmur. He was found to have native aortic valve infective endocarditis from a rare species of group D Streptococcusin his blood. The patient was also noted to be in an acute flare of Crohn's disease. The hospital course was complicated by florid heart failure from acute aortic insufficiency. He eventually improved after source control and appropriate antibiotic therapy. S. pasteuranis bacteremia and endocarditis are attributable to the patient's immunocompromised state as a result of infliximab treatment. While S. pasteuranis is infrequently grown in blood cultures, it is commonly found in normal gut flora. We hypothesize that it gained access to the bloodstream through the epithelium in the terminal ileum, which was inflamed due to an acute flare of Crohn's disease.

Leukocytoclastic Vasculitis and Myositis as Initial Manifestations of Crohn's Disease

Crohn's disease is a chronic inflammatory condition that mainly affects the digestive tract; however, it possesses extra-intestinal manifestations. We present a case of a 19-year-old male with a history of non-specific gastrointestinal (GI) symptoms of nausea, vomiting, and diarrhea who underwent a colonoscopy with a biopsy due to worsening GI symptoms. The colonoscopy was inconclusive for GI pathology. Three months later, he developed several symptoms, which were later indicative of leukocytoclastic vasculitis and myositis as extra-intestinal manifestations of Crohn's disease. The patient was started on high-dose prednisolone, which improved his symptoms remarkably, and the steroid dose was tapered gradually. He was subsequently followed up by the Rheumatology and Gastroenterology outpatient departments. The case reinforces the need for physicians to have a high index of suspicion in patients with non-specific GI symptoms presenting with new-onset cutaneous manifestations and myositis.

Anal Adenocarcinoma Arising From a Fistula-in-Ano: A Case Report

Crohn's disease (CD) is an inflammatory disease that can affect any portion of the gastrointestinal tract (GIT). Although it can present with a number of complications, perianal fistulae are among the most common consequences in patients with CD. In very rare cases, these patients can develop fistula-associated anal adenocarcinoma (FAAA). In this case report, we discuss a 72-year-old man with a long-term history of CD complicated by perianal fistulae, which failed medical and surgical management, ultimately presenting with acute anal pain in the outpatient setting. The physical examination revealed a seton traversing through a fistula surrounded by circumferential granulation tissue suspicious for malignancy. A biopsy of the tissue confirmed grade 3 mucinous-type infiltrating adenocarcinoma of the perianal skin. The patient was diagnosed with an anal verge malignancy associated with a fistula in the context of long-standing CD, and MRI staging demonstrated a T3N1 lesion with potential left inguinal node involvement. He completed neoadjuvant chemo-radiotherapy using capecitabine for five weeks with minimal tumor response, and subsequently, an abdominoperineal resection (APR) was performed with patient discharge on the fifth post-procedure day. Post-operative chemotherapy with oxaliplatin/leucovorin/fluorouracil was administered with minimal complications. Although rare, this report demonstrates the importance of consistent follow-up and mitigation of risk factors in patients with CD, along with the significance of prompt multimodal treatment in the event of developing FAAA.

Dilated Cardiomyopathy in Pediatric Crohn's Patient: Is It a Manifestation or Consequence of Therapy?

Inflammatory bowel disease (IBD) is a debilitating chronic disorder that is classified into Crohn's disease, ulcerative colitis, and unspecified which are marked by recurrent gastrointestinal inflammatory episodes. Anti-tumor necrosis agents, especially infliximab, are considered the cornerstone in disease management. However, rare but serious adverse effects related to infliximab have been reported. Limited studies reported cardiac adverse effects as a result of using infliximab in IBD especially in the pediatric age group. Here, we report a case of an 11-year-old boy known to have Crohn's disease, who was on a regular infusion of infliximab at a monthly basis which developed dilated cardiomyopathy with severe depression of myocardial function.

Protein-Losing Enteropathy in Crohn's Disease: Two Unusual Cases

Protein-losing enteropathy (PLE) occurs when protein losses throughout the gastrointestinal (GI) tract exceed the liver’s ability to produce new protein. This is a rare presentation of Crohn's disease and few reported cases of PLE related to Crohn’s exist in the literature. We describe two patients who presented with symptoms of PLE. After extensive diagnostic workup both were diagnosed with Crohn’s disease and managed with prednisone.

Severe Iron Deficiency Anemia Leading to Thrombocytosis With Arterial and Venous Thrombosis

A 45-year-old female who was a teacher by profession with a history of chronic asymptomatic anemia in the past presented to our hospital with complaints of intermittent fever for two weeks, cough with expectoration, dyspnea on exertion, and left upper limb edema for four days. She had a history of abdominal pain after food intake. She gave a history of having anemia for the past 23 years. Evaluation after admission showed raised inflammatory markers, marked thrombocytosis, and severe iron deficiency anemia. Further imaging in the form of a CT of the abdomen and thorax showed that she had a left-sided pleural effusion which showed an exudative picture, splenomegaly with a splenic infarct with a splenic abscess, and a suprarenal abdominal aorta thrombus. She was also found to have deep vein thrombosis (DVT) of the left subclavian and proximal internal jugular vein in a ultrasonogram (USG) Doppler. The workup done ruled out congenital and acquired causes of thrombosis and after extensive evaluation the patient was found to have unexplained thrombosis. The cause of unexplained thrombosis is the point of interest in this patient. Despite extensive workup, no precise cause for thrombosis, which was both arterial and venous in nature could be found out initially. Hence by exclusion, the possibility of secondary thrombocytosis causing the thrombosis was considered. Over the next few years, this patient underwent repeat esophageal endoscopies, colonoscopies, and capsule studies all without being able to pinpoint a diagnosis. Eventually three years later, a CT enteroscopy with biopsy showed the diagnosis of Crohn’s disease and the patient was started on appropriate immunosuppressive treatment for the same. There have been multiple case reports of thrombocytosis causing arterial or venous thrombus but not many have recorded both arterial and venous thrombosis in the same patient.

Extra-Intestinal Manifestations of Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is associated with extra-intestinal manifestations (EIMs) that tend to parallel intestinal activity and have a debilitating effect on the quality of life. EIMs primarily affect the joints, skin, and eyes with less frequent involvement of the liver, kidney, and pancreas. This article reviews the prevalence of musculoskeletal, dermatological, ocular, and other manifestations in IBD and their coalition with underlying intestinal inflammation. EIMs occurring independently of intestinal activity are managed by targeted therapies, categorical regimens, and specific treatments. On the other hand, EIMs paralleling the bowel activity are carefully monitored while the IBD is brought under control. Since the etiology of the disease is responsible for the development of the EIMs, the research scrutinizes the identified pathogenic mechanisms that tend to involve genetic susceptibility, aberrant self-recognition, and autoantibodies directed against organ-specific antigens shared by intestinal and extra-intestinal organs. This article also provides an overview of the epidemiology, clinical features, diagnostic modalities, and management of the EIMs associated with IBD.

An Unusual Case of Pyrexia of Unknown Origin

A previously fit and well 29-year-old man with no significant recent travel or contact history presented to the hospital with 11 days of feeling unwell, intermittent diarrhea, abdominal pain and a skin rash that was consistent with folliculitis. Despite resolution of these index symptoms he continued with recurring fever of 38.5 degrees centigrade and weight loss of six Kilograms over the next three weeks. Extensive investigations to find a cause for the unexplained persistent fever failed to reveal an etiology, hence fulfilling pyrexia of unknown origin definition (PUO). None of the three main causes of PUO, namely infections, autoimmune diseases or underlying malignancy, were confidently found. Colonoscopy was suggested following a review of the abdominal CT scan to investigate possible thickening of the bowel wall. A diagnosis of atypically presenting Crohn’s disease was eventually made and confirmed by colonoscopy and histology. The fever responded promptly to treatment of the Crohn's disease and he remained well at follow-up at six and 12 months after the initial presentation. In conclusion, it is important to keep in mind that PUO can be a rare initial presentation of inflammatory bowel disease in young adults with little or no gastrointestinal symptoms.

Hepatocellular Carcinoma in a Patient With Crohn's Disease

A 44-year-old woman with a 26-year history of Crohn’s disease (CD) presented with intermittent fever, vomiting, and watery diarrhea. Her medication included an elemental diet, mesalazine, and infliximab. Liver profile and viral hepatitis markers were normal. Computed tomography scans showed a hepatic tumor by chance. Serum tumor markers disclosed elevated protein induced by vitamin K absence-II. With a diagnosis of hepatocellular carcinoma (HCC), she underwent a hepatic resection of the tumor, revealing well-to-moderately differentiated HCC. The nontumor region of the liver disclosed the absence of cirrhosis or other diseases. Here, the development of HCC in CD without underlying liver diseases is discussed with a review of the literature.

Severity of Psychologic Stressors Reflects Course of Crohn's Disease in Two Siblings

A significant rise in Crohn's disease (CD) cases amongst first-degree relatives strongly suggests that inflammatory bowel disease (IBD) has a genetic component. Adherence to medical management is at the forefront for preventing disease relapse. However, given the role that stress places on the immune system, it is imperative to implore an individual's psychologic stressors to prevent future disease complications. This case of CD in two siblings, male and female, highlights the unique stress experienced by each patient at the time of symptom onset, the severity of their inflammatory symptoms, and their course of disease over several years. The male patient suffered from gender dysphoria and social anxiety for over a decade and had more chronic stress and severe complications of his disease. On the other hand, the stressors faced by his sister were periodic in nature and symptoms resided once stressful periods ended. For select patients, it is indicative that referral for psychotherapy should be considered as an ongoing mainstay of management. This case is intended to highlight the need for including psychotherapy in addition to medical management in order to treat IBD holistically.

Correlation Between the Gut Microbiome and Immunotherapy Response in Inflammatory Bowel Disease: A Systematic Review of the Literature

Inflammatory bowel disease (IBD) is an autoimmune disease associated with dysbiosis within the gastrointestinal tract. Characteristic taxonomic shifts of microbial populations are observed in disease progression and remission; however, despite similarities, there are many differences among individuals presenting with IBD including IBD subset, clinical course, and response to therapy. Much is still unknown about how these taxonomic shifts interact with immunotherapy and how genetic variants contribute. In this systematic review, we aimed to compile information on the interactions of the gut microbiome with immunotherapy in the course of disease and treatment of IBD patients. This systematic review was conducted as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the PubMed database was methodically screened for literature search including keywords and Medical Subject Headings (MeSH) terms for relevant articles. The quality appraisal was completed using the Cochrane Tool, Newcastle-Ottawa checklist, and the Scale for the Assessment of Narrative Review Articles (SANRA) checklist, as appropriate, and 11 relevant articles were included in this systematic review. Our review concludes that although there are characteristic taxonomic shifts between diseased and healthy patients, genetic variants are an important consideration in the predictive quality of disease and treatment decisions. The comparison between interactions of microbial populations and treatment in addition to the role of genetic variants may provide insight into treatment non-responders. Due to our limitations in current knowledge including the complexity of the microcosm, ethnic genetic variations among human populations, and our focus on relevant articles published in English over the past six years, we may have missed relevant studies. Future studies should focus on the comparison between Western and other cultural populations as well as further implementation of Genome-Wide Association Studies (GWAS) in clinical predictability.

Metastatic Vulval Crohn's Disease With Good Outcome on Ustekinumab

Vulval Crohn’s disease is a rare manifestation of Crohn’s disease. Although it is usually caused by a fistulating process, it may be a result of a metastatic disease process as well, the exact mechanisms of which are not well understood yet. Vulval Crohn’s disease may occur before the onset of bowel symptoms and may continue to be active while bowel symptoms are quiescent. Coupled with the fact that most vulval Crohn’s lesions are similar to other disease processes, it can prove to be a diagnostic challenge. Due to its rarity, no guidelines for treatment exist; however, most reports agree that when symptoms are not controlled with antibiotics and topical steroids, immunosuppressive medications such as oral steroids and biological agents are the way forward. Although surgery may be an option, data suggest that its use is scarce. We report the case of a 47-year-old Caucasian woman with bilateral metastatic vulval Crohn’s disease from a district hospital in the United Kingdom who responded well to ustekinumab. This is one of the first few cases reporting good clinical outcomes with the agent.

Biologic Therapy in HIV: To Screen or Not to Screen

Biologic therapy has revolutionized the management of chronic inflammatory diseases, including inflammatory bowel disease (IBD). Before the initiation of therapy, it is critical to rule out prior infection of chronic hepatitis B virus (HBV) and tuberculosis (TB). However, screening for human immunodeficiency virus (HIV) is not as routinely completed. We present a case of a 56-year-old male on ustekinumab for the management of Crohn's disease, found to have undiagnosed human immunodeficiency virus (HIV) with progression to acquired immunodeficiency syndrome (AIDS).

Primary Sclerosing Cholangitis in Crohn's Disease: An Atypical Complication

Crohn’s disease (CD) is a type of inflammatory bowel disease (IBD) that affects thousands of Americans, and it is commonly found in individuals aged between 20-30 years. Patients often present with abdominal pain and describe concerns of diarrhea, bloating, and weight loss. In this report, we discuss the case of a 21-year-old man who presented with diarrhea and intermittent hematochezia. He was admitted for a suspected lower gastrointestinal (GI) bleed. An abdominal CT scan demonstrated pancolitis with a mildly distended gallbladder. Subsequent sigmoidoscopy revealed a diagnosis of CD, which was confirmed with a biopsy. Following steroid therapy, the patient reported symptomatic improvement, although his alkaline phosphatase (ALP) levels continued to increase. Magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography (ERCP) revealed biliary strictures, which were suggestive of primary sclerosing cholangitis (PSC). This case highlights the importance of not ruling out CD in patients with PSC and understanding the differential clinical outcomes in patients with PSC with ulcerative colitis (UC) compared to those with CD. These differences include variations in colorectal carcinoma risk and severity of symptoms.

Psoas Abscess Presented as Right Hip Pain in a Young Adult With Crohn's Disease

A 27-year-old man with a past medical history of Crohn's disease presented in the Emergency Department complaining of right hip pain that has been going on for one month. At presentation, the patient was tachycardic. Physical examination revealed a positive psoas sign. Laboratory tests showed elevated white blood cells, C-reactive protein, and erythrocyte sedimentation rate. Computed tomography of the abdomen and pelvis revealed ileo-psoas fistula and psoas abscess. This rare case aims to provide awareness that intra-abdominal pathology should always be suspected in patients with referred hip pain and Crohn's disease. A thorough physical examination including maneuvers for assessment of possible iliopsoas inflammation should be effectively performed at the bedside to determine the likelihood of the condition and proper imaging should follow to confirm the diagnosis.

What can we learn from top-cited articles in inflammatory bowel disease? A bibliometric analysis and assessment of the level of evidence

BACKGROUND AND OBJECTIVES

Despite increasing number of publications in inflammatory bowel disease (IBD), no bibliometric analysis has been conducted to evaluate the significance of highly cited articles. Our objectives were to identify the top-cited articles in IBD, assessing their characteristics and determining the quality of evidence provided by these articles.

DESIGN AND OUTCOME MEASURES

IBD and related terms were used in searching the Web of Science to identify English language articles. The 50 top-cited articles were analysed by year, journal impact factor (JIF), authorship, females in authorship, institute, country and grants received. The level of evidence was determined using the Oxford Centre for Evidence-Based Medicine guidelines.

RESULTS

The number of citations varied from 871 to 3555 with a total of 74 638, and a median 1339.50 (IQR=587). No correlations were found between the number of citations and number of years since publication (r=0.042, p=0.771), JIF (r=0.186, p=0.196), number of authors (r=0.061, p=0.674), females in authorship (r=0.064, p=0.661), number of institutes (r=0.076, p=0.602), number of countries (r=0.101, p=0.483) or number of grants (r=-0.015, p=0.915). The first authors were from the USA (n=24), the UK (n=6), Germany (n=5), France (n=5), Belgium (n=3) and Canada (n=3). The levels of evidence were 12 articles at level 1b, 9 articles at level 3a and 15 articles at level 3b and fewer were at other levels.

CONCLUSIONS

Research papers represented 66% of articles. The majority of items have reasonably high levels of evidence, which may have contributed to the higher number of citations. The study also shows a gender gap in authorship in this area.

Low Incidence of Dysplasia and Colorectal Cancer Observed among Inflammatory Bowel Disease Patients with Prolonged Colonic Diversion

BACKGROUND

In inflammatory bowel disease (IBD), many scenarios call for fecal diversion, leaving behind defunctionalized bowel. The theoretical risk of colorectal cancer (CRC) in this segment is frequently cited as a reason for resection. To date, no studies have characterized the incidence of neoplasia in the diverted colorectal segments of IBD patients.

METHODS

A retrospective cohort analysis was conducted for IBD patients identified through a tertiary care center pathology database. Patients that had undergone colorectal diversion and were diverted for ≥ 1 year were included. Incidence of diverted dysplasia/CRC was calculated for Crohn's disease (CD) and ulcerative colitis (UC) with respect to diverted patient-years (dpy) and patient-years of disease (pyd).

RESULTS

In total, 154 patients comprising 754 dpy and 1984 pyd were analyzed. Only 2 cases of diverted colorectal dysplasia (CD 1, UC 1) and 1 case of diverted CRC (UC) were observed. In the UC cohort (n = 75), the rate of diversion-associated CRC was 4.5 cases/1000 dpy (95% CI 0.11-25/1000) or 1.5 cases/1000 pyd (95% CI 0.04-8.2/1000). In the CD cohort (n = 79), no patients developed CRC, although a dysplasia rate of 1.9 cases/1000 dpy (95% CI 0.05-11/1000) or 0.77 cases/1000 pyd (95% CI 0.02-4.3/1000) was observed. All patients developing neoplasia had disease duration > 10 years and microscopic inflammation.

CONCLUSIONS

Diverted dysplasia occurred infrequently with rates overlapping those reported in registries for IBD-based rectal cancers. Neoplasia was undetected in patients with < 10 pyd, regardless of diversion duration, suggesting low yield for endoscopic surveillance before this time.

The emerging role of leptin antagonist as potential therapeutic option for inflammatory bowel disease

Inflammatory bowel disease (IBD) is a chronic relapsing immune-mediated inflammatory disorder that affects millions of people around the world. Leptin is a satiety hormone produced primarily by adipose tissue and acts both centrally and peripherally. Leptin has been shown to play a major role in regulating metabolism, which increases during IBD progression. Leptin mediates several physiological functions including elevated blood pressure, tumorogenesis, cardiovascular pathologies and enhanced immune response in many autoimmune diseases. Recent development of a leptin mutant antagonist that blocks leptin activity raises great hope and opens up new possibilities for therapy in many autoimmune diseases including IBD. To this end, preliminary data from an ongoing study in our laboratory on pegylated leptin antagonist mutant L39A/D40A/F41A (PEG-MLA) treatment shows an inhibition of chronic colitis in IL-10-/- mice. PEG-MLA effectively attenuates the overall clinical scores, reverses colitis-associated pathogenesis including a decrease in body weight, and decreases systemic leptin level. PEG-MLA induces both central and peripheral leptin deficiency by mediating the cellular immune response. In summary, after blocking leptin activity, the correlative outcome between leptin-mediated cellular immune response, systemic leptin levels, and amount of adipose tissue together may provide new strategies for therapeutic intervention in autoimmune diseases, especially for intestinal inflammation.

Serum anti-glycan antibody biomarkers for inflammatory bowel disease diagnosis and progression: a systematic review and meta-analysis

BACKGROUND

Anti-glycan antibody serologic markers may serve as a useful adjunct in the diagnosis/prognosis of inflammatory bowel disease (IBD), including Crohn's disease (CD) and ulcerative colitis (UC). This meta-analysis/systemic review aimed to evaluate the diagnostic value, as well as the association of anti-glycan biomarkers with IBD susceptible gene variants, disease complications, and the need for surgery in IBD.

METHODS

The diagnostic odds ratio (DOR), 95% confidence interval (CI), and sensitivity/specificity were used to compare the diagnostic value of individual and combinations of anti-glycan markers and their association with disease course (complication and/or need for surgery).

RESULTS

Fourteen studies were included in the systemic review and nine in the meta-analysis. Individually, anti-Saccharomyces cervisiae antibodies (ASCA) had the highest DOR for differentiating IBD from healthy (DOR 21.1; 1.8-247.3; two studies), and CD from UC (DOR 10.2; CI 7.7-13.7; seven studies). For combination of ≥2 markers, the DOR was 2.8 (CI 2.2-3.6; two studies) for CD-related surgery, higher than any individual marker, while the DOR for differentiating CD from UC was 10.2 (CI 5.6-18.5; three studies) and for complication was 2.8 (CI 2.2-3.7; two studies), similar to individual markers.

CONCLUSIONS

ASCA had the highest diagnostic value among individual anti-glycan markers. While anti-chitobioside carbohydrate antibody (ACCA) had the highest association with complications, ASCA and ACCA associated equally with the need for surgery. Although in most individual studies the combination of ≥2 markers had a better diagnostic value as well as higher association with complications and need for surgery, we found the combination performing slightly better than any individual marker in our meta-analysis.