A 45-year-old lady presents with recurrent abdominal pain which she has experienced for a few years. She also complains of recurrent oral ulceration and persistent vaginal discharge and ulceration. She has no fever and denies any diarrhoea or weight loss. Colonoscopy shows a large oval-shaped ulcer in the ileum; otherwise no other colonic mucosal lesions are noted.
•Afebrile, pulse 72 bpm, BP 125/80mmHg, SaO2 97% on RA.
•Her general appearance is unremarkable.
•Examination of the hands reveals no clubbing and normal-appearing palmar creases.
•Head and neck examination is unremarkable and no cervical lymph nodes are palpable. There are multiple aphthous ulcers in the oral cavity, but no oral thrush.
•Cardiovascular: HS dual, no murmur.
•Her chest is clear on auscultation.
•Abdominal examination is unremarkable.
•No signs of oedema.
On gynaecological examination, multiple vaginal ulcers are noted on physical examination but no definite fistula openings are noted.
What is your differential diagnosis?
The differential diagnosis includes Behçet’s disease, Crohn’s disease and infective causes including intestinal tuberculosis and Cytomegalovirus (CMV) colitis.
What blood test(s) would you order?
•Liver function tests.
All blood tests are unremarkable.
What further investigations would you order?
A chest X-ray (Figure 6.1) and an MRI of the pelvis. A small-bowel follow-through series can also be useful (Figures 6.2–6.4). CT enterography/MR enterography are other modalities used for small bowel work-up.
Please describe what you see
The chest X-ray in Figure 6.1 shows a clear lung field. The small-bowel follow-through series (Figures 6.2–6.4) does not reveal any fistulae or strictures. The MRI of the pelvis (not seen here) does not reveal any fistulae.