1. Brief history The patient is a 58-year-old male. He was admitted to the hospital on August 24, 2002 with “recurrent black stools for 6 months, aggravated for 3 weeks with malaise”. He had black stool for 6 months with no obvious cause and malaise, which worsened in the past 3 weeks, with increased frequency and volume of black stool, without nausea and vomiting, abdominal pain and diarrhea, recurrent fever and night sweats, and no skin yellowing. There was no wasting and no progressive weight loss during the course of the disease. In January 2002, he was hospitalized in an outside hospital for 2 weeks, and the bone marrow aspiration examination concluded that he had “microcytic hypochromic anemia, hypotrichosis of iron and iron granulocytes outside the bone marrow”, and the colonoscopy suggested “chronic colitis, colonic spasm, and capillary dilatation in the colon”. “The patient was discharged from the hospital after symptomatic treatment. In April 2002, he underwent gastroscopy in our hospital and was diagnosed with superficial erosive sinusitis with bile reflux. The nuclear gastrointestinal bleeding examination did not show any obvious bleeding foci. Barium enema examination did not show any abnormality, but fundus hemorrhage occurred during hospitalization, and fundus angiography indicated “optic disc vasculitis”. Past history: Cured of acute hepatitis A in 1982, “optic nerve papillitis” in 1991, history of gastric ulcer combined with acute bleeding in 1992, denied history of tuberculosis and typhoid. He denied any history of contact with epidemic water and no history of trauma. The patient denied any history of repeated skin and mucous membrane bleeding, denied any history of hypertension or heart disease.
2. physical examination T: 37.6℃, P: 87 beats/min, R: 20 beats/min, BP: 15.3/10 kPa. normal development, nutritional deviation. The mental state was clear, with a severe anemic appearance. Superficial lymph nodes were not enlarged, sclera was not yellowish, neck (-). The respiratory sounds of both lungs were clear, and no dry or wet rales were heard. The heart rate was 87/min and the rhythm was normal. A grade 2 systolic murmur could be heard in the precordial region. The abdomen was full, with a postoperative scar on the right lower abdomen, soft, no tenderness, no pressure pain, rebound pain, no muscle guards, no masses were found, and the liver and spleen were not palpable under the ribs. Murphy’s sign (-), no mobile turbid sounds. Bowel sounds were 3 times/minute. No swelling of both lower limbs. There is no abnormality in the nervous system.
3. Laboratory examination: leukocytes 4.8×109/L, neutrophils 71%, hemoglobin 52g/L, platelets 271×109/L, fecal routine (-), urinary routine (-). Total protein was 65 g/L, albumin 35 g/L. Alkaline phosphatase (AKP), γ-glutamyl transpeptidase (γ-GT), glutamate aminotransferase (AST), alanine aminotransferase (ALT), serum total bilirubin, direct bilirubin, urea, creatinine and blood glucose were normal. All hepatitis B virological indicators were negative, and hepatitis C virus antibody was negative. Chest X-ray was free of old tuberculosis and no obvious active lesions were seen. The electrocardiogram was normal. Emergency gastroscopy suggested superficial gastritis. Oral method barium small intestine enema angiography did not show any abnormality. CT examination of the upper abdomen did not show any abnormality.
4.First consultation (August 25) The internist reported the medical history.
Resident physician The patient’s characteristics: (1) male, 58 years old, duration of disease 6 months. (2) The main clinical manifestation is recurrent black stools aggravated for 3 weeks in 6 months. (3) No abdominal pain, no fever, nausea, vomiting, diarrhea, mucopurulent stools. (4) History of tuberculosis, typhoid and other infectious diseases, and history of optic nerve papillitis were denied. (5) No history of epidemic water exposure. (6) General condition was acceptable, with severe anemia and no yellow sclera. No abdominal mass was found, and the mobile turbid sound was negative. (7) Laboratory examination: leukocytes 4.4×109/L, neutrophils 68%; chest X-ray without old tuberculosis, no obvious active lesions. The electrocardiogram was normal. Emergency gastroscopy suggested superficial gastritis. No abnormality was seen on oral method barium small intestine enema angiography. The patient’s diagnosis is currently unknown.
Attending physician: The patient presented with chronic gastrointestinal bleeding with predominantly black stools, a previous history of unexplained vague pain in the right lower abdomen, and no other specific medical history. (1) First of all, black stools due to recurrent bleeding outside the gastrointestinal tract such as nasopharynx and biliary tract should be excluded. This patient had no epistaxis, abdominal pain, fever, scleral yellow stain, no obvious positive signs on physical examination, and no nasopharyngeal or biliary tract disorders were found in laboratory tests, so such diseases could be excluded. (2) The patient’s repeated gastroscopy (including emergency gastroscopy) did not reveal any bleeding lesions in the stomach or duodenum, so upper gastrointestinal bleeding could be excluded. (3) Lower gastrointestinal bleeding. (1) The patient has performed colonoscopy, barium enema examination did not find intestinal inflammatory disease and masses, and there is no change in stool habits, no diarrhea, mucopurulent stools, so the diagnosis of colon and rectal cancer are based on insufficient. ②Older patients with large bleeding volume and severe anemia should consider the possibility of mesenteric vascular malformation, and further mesenteric angiography can help diagnose and differential diagnosis. ③Colonoscopy reveals colon capillary dilation, but there is no capillary dilation on the body surface skin, and there is no family history, so the diagnosis of colonic capillary dilation is also based on insufficient evidence. ④Small intestinal diseases, including small intestinal tumors and small intestinal inflammatory diseases, there is a lack of specific tests for small intestinal diseases, although no abnormalities were found in the oral method of small intestinal barium enema angiography, still small intestinal diseases cannot be excluded.
Chief physician: This patient is a difficult case, and we agree with the analysis of the attending physician. We must clarify the diagnosis before formulating the treatment plan, and we need to exclude small bowel tumor and mesenteric vascular malformation before considering hereditary capillary dilation and making corresponding treatment. Barium enema of small intestine with vascular DSA can be performed again by intubation method, and laparoscopic exploration or dissection can be considered if necessary.
5. Second consultation (September 2) Further examination: vascular DSA examination: superior and inferior mesenteric arteries and abdominal trunk arteriogram did not show any abnormality. External hospital twice intubation method small intestine barium enema suggests segmental stenosis of ileum, consider the possibility of malignant infiltration, our hospital performed oral method small intestine barium enema suggests segmental stenosis of ileum, consider the possibility of inflammatory granuloma according to the peristaltic nature of the lesion intestinal section.
Chief physician: According to the above examination results the site of pathogenesis can be located in the ileum, while other diseases can be excluded. Ileal segmental stenosis should be considered (1) ileal tumors such as malignant lymphoma, adenocarcinoma, carcinoid tumor, smooth muscle tumor, smooth muscle sarcoma, etc. (2) Ileal inflammatory diseases such as intestinal tuberculosis, clonal disease, etc. Combined with the observation of peristalsis of the diseased intestinal segment by barium enema of small intestine in one oral method, the possibility of tumor lesion is considered to be small. The proposed dissection and intraoperative rapid pathological examination will be performed.
6, the third consultation (September 18) intraoperative investigation: no ascites, lesion intestinal section 70cm~140cm from the end of ileum, about 70cm long, regular distribution of 7 ulcers, each about 3cm long, around the intestine a circle, intestinal lumen narrowing, lesion intestinal section plasma membrane color is normal, palpable sand sense, intestinal mesentery did not find enlarged lymph nodes. Pathology showed 7 oval ulcers on the mucosal surface, and the long axis of the ulcers was perpendicular to the intestinal canal. Microscopically, there was necrotic tissue on the ulcer surface, and epithelial granulation tissue proliferation with lymphocytic and plasma cell infiltration in the intestinal wall. The diagnosis of segmental enteritis (clonorchiasis) is likely, with negative TB-DNA.
Chief physician: The patient’s current diagnosis is clear. Combined with the medical history, recurrent right mid-lower abdominal vague pain for more than 10 years, history of optic nerve papillitis, pathological consideration of segmental enteritis, and no history of tuberculosis, no tuberculosis foci on chest radiograph, no characteristic manifestations of tuberculosis on pathological examination, and negative TB-DNA, the diagnosis of segmental enteritis is established.
Crohn’s disease is a segmental chronic inflammatory bowel disease of unknown cause, which can occur in any part of the gastrointestinal tract, including 41%-55% in the ileocecal region, 30%-40% in the small intestine, and 14%-26% in the colon. The clinical treatment of Crohn’s disease is still based on internal drug therapy, and there are two types of indications for surgery for Crohn’s disease: patients who are difficult to control with drug therapy or who have severe side effects of drug therapy, and patients with severe complications including massive bleeding, perforation, internal and external fistulae forming abscesses, persistent and recurrent stenosing obstruction, and fulminant colitis or toxic megacolon where drug therapy has failed. The main surgical options are stenoplasty, resection of the diseased bowel segment, and bypass of the intestinal disc. This patient underwent resection of the diseased bowel segment and recovered well after surgery. He was free of black stool and in good general condition at the outpatient follow-up for three months.