History
A 51-year-old gentleman initially presented with loose bowel motions and abdominal pain in 2008. He had a past history of peptic ulcer disease treated with a partial gastrectomy. Private colonoscopy showed ileocecal colitis. Colonic biopsy showed acid-fast bacilli on staining, but culture for tuberculosis was negative. Anti-tuberculosis treatment was commenced for a duration of 10 months. Upon follow-up, repeat colonoscopy still showed ileocecal valve ulceration. Repeat biopsy was negative for acid-fast bacilli and tuberculosis DNA polymerase chain reaction (TB-PCR).
He has now been referred to a tertiary hospital in view of worsening symptoms of abdominal cramps and bowel opening up to three times per day. He also complains of loss of appetite and weight loss of around 1kg in the past month. He has no symptoms of gastrointestinal bleeding, and also no mucus per rectum. He denies any oral or genital ulcers, joint pain or eye symptoms.
What is your differential diagnosis?
The differential diagnosis includes intestinal tuberculosis (ITB), Crohn’s disease (CD) and Behçet’s disease.
Physical examination
•Afebrile, pulse 90 bpm, BP 134/72mmHg, SaO2 98% on RA.
•Hydration is satisfactory.
•Examination of the hands reveals no clubbing and normal-appearing palmar creases.
•On examination of the head and neck, the oral cavity is normal with no ulceration.
•Cardiovascular: HS dual, no murmur.
•His chest is clear on auscultation.
•Abdominal examination reveals a soft abdomen, with tenderness over the right lower quadrant and no definite mass.
•No signs of oedema.
Does this narrow your differential diagnosis? What diagnosis does the physical examination suggest?
Yes. The lack of mucosal ulceration on physical examination and no history of symptoms suggestive of uveitis or skin pathergy are less suggestive of Behçet’s disease.
Investigations
•CBC:
–WBC 10 x 109/L;
–haemoglobin 10.4g/dL;
–platelets 369 x 109/L.
•ESR 46mm/hr.
•CRP 51mg/L.
•Liver and renal function tests are grossly normal.
What other blood tests would you order?
•Iron profile: Fe 4μmol/L, TIBC 26μmol/L, Fe 14%.
What do these laboratory data suggest?
Active inflammation with iron deficiency anaemia; the origin may be from the gastrointestinal tract.
How would you proceed?
In view of worsening symptoms and poor response to previous treatment, a repeat colonoscopy should be arranged (Figure 3.1
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