Granulomatosis Colitis

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Granulomatosis Colitis

• Presented by
• Dr. Leon Wolf

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History

• C.C. Anemia and HO
• 45 yo male asymptomatic
• PMH h/o goiter, Rx Synthroid
• FH CAD DM Colonic polyps
• SH born outside of USA, postal worker
• ROS w/o wt loss, fever w/o cough,
  sputum hemoptysis

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Physical Exam

• Healthy appearing wt.220 T.98.6
• HEENT R. neck fullness
• Lungs clear
• Abd soft w/o masses, LSKK
• Rectal w/o masses, HO
• Ext w/o joint fullness or tenderness
• Skin w/o rashes

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LAB

• Hgb 10.6, MCV 77
• WBC 8,900 normal differential
• CMP normal
• CEA 1.4

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ENDOSCOPIC EVALUATION

• Colon cecal villous,nodular friable lesion
• EGD gastric erythema
• esophageal nodule
• Microscopic Colon granulomatous colitis
• Stomach mild gastritis
• Esophagus papilloma

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Clinical Course

• RX Pentasa, iron
• CXR negative
• SBFT negative
• CTABD/PELVIS negative
• PPD positive 20yrs ago

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Re-Colonoscopy

• Villous, nodular lesion
• Open ileocecal valve
• Ileal lymphoid hyperplasia
• Cultures AFB,Fungus, OP
• Stains

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Diseases to Consider in the Differential
Diagnosis

• Gastrointestinal diseases
• Inflammatory bowel disease
• Crohns disease
• Ulcerative colitis
• Nodular lymphoid hyperplasia
• Celiac disease
• Necrotizing enterocolitis

• Gastrointestinal diseases continued
• Behçets disease
• Eosinophilic gastroenteritis
• Hirschsprungs disease with necrotizing
  enterocolitis
• Neoplasms
• Anatomical or vascular abnormalities

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Diseases to Consider in the Differential
Diagnosis Continued

• Hematologic diseases
• Chronic granulomatous disease
• Langerhans cell histiocytosis
• Familial hemophagocytic lymphohistiocytosis

• Systemic inflammatory diseases
• Sarcoidosis
• Wegeners granulomatosis
• Juvenile dermatomyositis
• Juvenile rheumatoid arthritis
• Systemic lupus erythematosus

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Diseases to Consider in the Differential
Diagnosis continued

• Infectious diseases
• Mycobacterium tuberculosis infection
• M. avium infection
• Yersinia infection
• Giardia lamblia infection
• Tropheryma whippelii infection
• Bartonella henselae infection

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Differential DX

• Yersinia
• Sarcoidosis
• Crohns disease
• Tuberculosis

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Yersinia

• Gram negative rod
• Contaminated milk, milk products
• Acute manifestations
• Enterocolits most common lt5 yo
• Adenitis, ileitis gt5 yo
• Bacteremia in pts underlying disease
• Reiters syndrome
• Self limited 3 to 4 wks

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Sarcoidosis

• Gastrointestinal involvement uncommon other than
  liver granulomatosis
• Stomach primarily,bleeding ulcerations
• Small intestine nodal or lymphatic blockage
• Esophageal obstruction lymph nodes or
  infiltration
• Pulmonary or renal involvement with above

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Tuberculosis

• Koch 1882 ID bacillus
• Primary pulmonary disease
• Pre antiboitics 55-90 GI involvement
• Proportional to pulmonary disease
• Post antiboitics GI disease have lt50 pulmonary
  tb evidence

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Tuberculosis organisms

• M. tuberculosis
• M.bovis
• (M. avium)

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Patients At Higher Risk

• Immigrants (travel endemic areas)
• AIDS
• Urban poor
• Living on reservations
• Prisoners
• NH residents

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Gastrointestinal Areas

• Ileocecal/ileal approx 75
• Asc.colon appendix approx 20
• Uncommon jejunum,stomach,esophagus,
• sigmoid/rectum, anal
• Multiple areas-skip areas

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Clinical Sx and Exam

• Non-specific sx 80-90
• pain
• wt loss
• diarrhea/constipation
• blood in stools
• PE abdominal mass
• perianal lesions

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Complications

• Hemorrhage
• Perforation
• Obstruction
• Fistula formation
• Malabsorption

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Endoscopic Findings

• Ulcerative 60
• Hypertrophic 10
• Mixed 30
• Circumferential ulcers
• Scarred open IC valve

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Radiological Findings

• BE/SBFT ulcers
• thickening/distortion
• stenosis
• pseudopolyps
• CT adenopathy-central necrosis
• mass
• calcified nodes

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Diagnosis

• Stain lt20
• PCR 80
• Culture lt30 mucosal biopsies
• ? surgical specimen esp
  node
• n.g. stool esp with pulm
  disease
  
• Presumptive PPD, CXR
• Therapeutic Response

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Clinical Course

• Iron RX increase hgb felt less dizzy
• AFB culture
• M.gordonia

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