Saudi Journal of Gastroenterology
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CASE REPORT Table of Contents   
Year : 2000  |  Volume : 6  |  Issue : 2  |  Page : 99-101
Crohn's Ileiti's presenting with massive gastrointestinal hemorrhage - case report and review of literature


1 Department of Medicine, College of Medicine & King Khalid University Hospital, Riyadh, Saudi Arabia
2 Department of Radiology, College of Medicine & King Khalid University Hospital, Riyadh, Saudi Arabia

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Date of Submission18-May-1999
Date of Acceptance04-Jul-1999
 

How to cite this article:
Rahmatulla RH, Al Boukai AA, Al Akwaa AM, Al Amri SM, Laajam MA. Crohn's Ileiti's presenting with massive gastrointestinal hemorrhage - case report and review of literature. Saudi J Gastroenterol 2000;6:99-101

How to cite this URL:
Rahmatulla RH, Al Boukai AA, Al Akwaa AM, Al Amri SM, Laajam MA. Crohn's Ileiti's presenting with massive gastrointestinal hemorrhage - case report and review of literature. Saudi J Gastroenterol [serial online] 2000 [cited 2019 Jul 23];6:99-101. Available from: http://www.saudijgastro.com/text.asp?2000/6/2/99/33488


Gastrointestinal bleeding in Crohn's colitis is well recognized, whereas massive gastrointestinal (GI) bleeding as the initial symptom of Crohn's ileitis is rare. Only few cases of such presentations are documented in the literature[1]. We report a case of a young Saudi man presenting with massive gastrointestinal bleeding, in whom Crohn's disease of the small bowel was established as the source of bleeding. A review of literature of such a rare presentation in Crohn's disease will be discussed.


   Case Report Top


A 24-years-old Saudi man was admitted with history of passing large amounts of black tarry stools three times on the day of admission which was associated with dizziness. Three weeks earlier he had noted passing similar black-colored stools lasting for three days. At that time he was hospitalized at another institution and received blood transfusion (hemoglobin level and units of blood given not available). There was one year history of diffuse mild crampy abdominal pain, relieved by defecation with occasional bouts of non bloody watery diarrhea lasting for a few days followed by normal bowel habits. There was a history of weight loss of around 7 kg during this period. He was seen in a surgical clinic one year back for perianal abscess and fistula.

He denied history of fever, night sweats, joint pains or skin rashes. There was no history of nonsteroidal anti-inflammatory drug use or bleeding disorder or relevant family history. He is a smoker for the last few years. On presentation he was afebrile, hypotensive, tachycardic, pale and dehydrated with mild epigastric tenderness. There was no evidence of lymphadenopathy or palpable abdominal masses. Perianal examination revealed multiple sinus scars. His hemoglobin on admission was 10 g/dl with hematocrit of 30%, white cell count of 14,000 and ESR of 28 mm at the end of the first hour. The renal functions, liver functions, along with the lipid and bone profiles were normal. Repeated stool examinations did not show ova, cyst or parasites with negative cultures for bacteria. Upon admission lie continued to pass black stools and his hemoglobin dropped on the day of admission form 10 g/dl to 7.1 "/dl requiring 2 units of packed red blood cell (PRBC) transfusion.

He complained of dizziness and was hypotensive, but responded to intravenous fluids and PRBC transfusion. Esophagogastroduodenoscopy (EGD), colonoscopy and Meckel's isotope scan failed to disclose a source for the bleeding. However at colonoscopy, the ileocaecal valve was stenosed with scarring and intubation was not possible. Red blood cell (RBC) labeled scan showed blood pool in the ascending colon seen at 20 and 23 hours post injection. Tuberculin skin test was negative and chest radiograph was normal. His melena recurred after a week and again his hematocrit dropped from 30% to 23%. A repeat EGD endoscopy was normal. Repeat labeled RBC and HMPAO White blood cell labeled scans revealed increased activity in the distal ileum and ascending colon.

Small bowel enema showed extensive deep longitudinal and transverse fissuring in the terminal ileum giving "cobble-stone" pattern as well as "rose thorn" appearance with fistulous communication between small bowel loops, the findings were consistent with Crohn's disease [Figure - 1]. Patient was started on intravenous methyl prednisolone forty milligrams and patient had no further episodes of melena during his two week hospital stay. He was discharged on the same dose of oral prednisolone alone. When seen a month later in the clinic, he was in good health with no recurrence of bleeding and normal bowel habits, so was continued on tapering dose of prednisolone only. He gained two kilograms in weight.


   Discussion Top


Crohn's disease is a chronic transmural inflammation that may occur anywhere in the gastrointestinal tract from mouth to anus. It commonly affects the terminal ileum, colon and the perianal region. Most symptomatic patients can be classified into three anatomic groups on the basis of radiologic and endoscopic findings: (a) Small bowel disease alone (30-40%), (b) Disease of both small and large bowel (40-55%) and (c) Large bowel disease alone (15-25%)[4]. In patients with small bowel involvement, the terminal ileum will be involved in at least 90% of the cases. Crohn's disease primarily affects younger age groups, especially those in their tens and twenties, as in this case; although there may be a second peak in the eighth decade of life.

Crohn's disease in Saudi-Arabia is uncommonly seen, in contrast to ulcerative colitis. Gindan et al reported twelve cases of Crohn's disease as compared to seventy-six cases of Ulcerative Colitis over a twelve-year period in a tertiary teaching hospital in Al Khobar, Saudi Arabia. Hossain et al reported Crohn's disease in seven Arabs, three of whom were Saudi nationals. Recently there is a clinical impression that Crohn's disease is on the increase, especially among young adults[7],[8],[9],[10],[11] . Since terminal ileum is the most commonly involved, the disease usually presents as a chronic history of recurrent episodes of right lower quadrant abdominal pain, diarrhea and weight loss. Patients may also present with perianal fistulae, fissures and abscesses, perirectal and perianal lesions appearing in about one third of the patients with Crohn's disease. Intestinal obstruction may be the presenting gastrointestinal symptom in 25% of the cases. Gross gastrointestinal bleeding is seen in about half the patients with exclusively colonic involvement and in less than a fourth of those with ileocolitis[4]

However, some authors claim that gastrointestinal bleeding is more common in patients with Crohn's disease of the small bowel, than originally thought as was seen in our case[1]. Medline search of the English literature between 1978 and 1998 revealed only 38 similar cases of Crohn's disease presenting with massive gastrointestinal bleeding. William et al in 1995 reported 4 such cases in addition to 34 others from the literature[1]. Three out of the four cases required surgical intervention (ileocolectomy), whereas the fourth case responded to medical treatment (mode of treatment not specified in the paper). It was postulated that GI bleeding from the small bowel occurs commonly in younger patients due to acute and shallow mucosal ulceration and an increased mucosal and submucosal friability as compared to the older patients in whom the mucosal and submucosal thickening progress to stenosis[1],[2]. The diagnosis of Crohn's disease in our patient was suspected because of the presence of perianal lesions combined with abdominal symptoms and weight loss. As upper and lower gastrointestinal endoscopies were negative, a small bowel barium enema was performed. This showed the characteristic radiologic features of Crohn's disease of the small bowel. The diagnosis of Crohn's disease is usually made on the basis of typical radiological findings of the small bowel. Endoscopy with biopsy is complementary to radiology in making the diagnosis. The endoscopic mucosal biopsy is limited by superficial depth of tissue sampled, since Crohn's disease causes transmural involvement[4]. Patients with Crohn's may undergo surgical intervention at some stage in their life due to intestinal obstruction, fistulation or gastrointestinal bleeding[1],[4]. Gastrointestinal bleeding may stop spontaneously or after institution of medical therapy in some patients as in our case. However, most patients with massive bleeding need ileocolectomy to stop the bleeding[1],[2],[5]. In a reported series of 38 patients with massive gastrointestinal bleeding due to Crohn's disease, 91% of the cases required surgery. Preoperative mesenteric arteriography has been used to localize the site of bleeding and is helpful in limiting the surgical excision of the diseased bowel[1],[3],[6].

In conclusion our patient is one of the rare cases of Crohn's disease limited to the small bowel initially presenting as massive gastrointestinal hemorrhage. It is an uncommon cause of gastrointestinal bleeding in Saudi Arabia especially in the young, but should be considered in young patients presenting with small bowel bleeding after excluding other common conditions like Meckel's diverticulitis.

 
   References Top

1.Cirocco WC, Reilly JC, Rusin LC. Life threatening hemorrhage and exsanguination from Crohn's disease, report of four cases. Dis Colon Rectuml995;38:85-95.  Back to cited text no. 1    
2.Rubin M. Herrington JL. Schneider R. Regional enteritis with major Gastro-intestinal hemorrhage as the initial manifestation. Arch Intern Med 1980;140:217-19.  Back to cited text no. 2    
3.Podolny GA. Crohn's disease presenting with massive lower Gastro-intestinal hemorrhage. Am J Roentgenol 1978:130:368-70.  Back to cited text no. 3    
4.Kornbluth A. Sachar. DB, Salomon.P. Crohn's Disease. In:Feldman M, Sharschmidt BF, Sleisenger MH eds. Gastrointestinal and Liver Disease, Philadelphia. Saunders 1998:1708-34.  Back to cited text no. 4    
5.Farmer RG. Lower gastro-intestinal bleeding in inflammatory bowel disease. Gastroenterology JPN 1991;26(suppl.)3:93-100.  Back to cited text no. 5    
6.McGarrity TJ, Manasse JS, Koch KL, Weidner WA. Crohn's disease and massive lower gastrointestinal bleeding, angiographic appearance and two case reports. Am J Gastroenterol 1987:82:1096-9.  Back to cited text no. 6    
7.Isbister WH, Hubler M. Inflammatory bowel disease in Saudi Arabia: Presentation and initial management J Gastroenterol Hepatol 1998;13:1119-24.  Back to cited text no. 7    
8.Hossain J, Al Mofleh IA, Laajam MA, Al Rashed RS, et al. Crohn's disease in Arabs. Annals of Saudi Medicine 1991;11:40-6.  Back to cited text no. 8    
9.Mokhtar A, Khan MA. Crohn's disease in Saudi Arabians. Saudi Med J 1982;3:270-4.  Back to cited text no. 9    
10.Laajam MA. Crohn's disease versus tuberculosis: case report. East Afr Med J 1989;9:620-5.  Back to cited text no. 10    
11.Gindan YMA, Satti MB, Quorain AA, Hamdan AA. Crohn's disease in Saudi Arabia. Saudi J. Gastroenterol 1996;2:150-5.  Back to cited text no. 11    

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Correspondence Address:
Mohamed A Laajam
Department of Medicine, KKUH, P.O. Box 2925 (38), Riyadh 11461
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


PMID: 19864721

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