Crohn Disease with Gastritis and Constipation without Diarrhoea: A Diagnostic EnigmaAbstractThere are multiple atypical manifestations of Crohn disease which sometimes delay diagnosis or even more often result in complete misdiagnosis especially in poorly equipped facilities. This is the case of an elderly woman with Crohn disease who presented with gastritis and constipation. She had hitherto been wrongly managed for peptic ulcer disease based mainly on her symptoms. Further workup revealed the actual diagnosis, but only after some years of failed symptomatic management. This case aims to improve awareness on the sundry variants of Crohn disease presentation and to encourage clinicians to reduce complacency in diagnosing apparently simple conditions.Keywords: Crohn disease, gastritis, intestinal obstruction, constipationIntroductionCrohn disease falls under the umbrella of inflammatory bowel disease and can involve any part of the gastrointestinal tract. It is many a time misdiagnosed or diagnosed late.1 This is even more so when health centres are not well equipped to go through what would be for them, an investigative wild goose chase. Common presentations include abdominal pain, diarrhea, unintentional weight loss and haematochezia, and is usually seen in young adults.2There are however enigmatic variants that do not present with these tell-tale symptoms. These include those that manifest with obstructive symptoms, dyspeptic symptoms as well as those with more extra-intestinal than gastrointestinal symptoms such as arthritis, aphthous stomatitis and uveitis.Case PresentationThis is the case of a 78-year old Ghanaian woman who was admitted on account of an acute exacerbation of Crohn disease. She was diagnosed about a year prior to the index presentation, after being managed for incomplete intestinal obstruction, by subsequent workup and lower GI endoscopy. No treatment was started after the diagnosis on the patient’s request. This current presentation was a week’s history of severe generalized abdominal pain graded 9/10, colicky in her lower abdomen and burning in her epigastric region. It was associated with constipation (hard, scanty, infrequent stools averaging once a week) and non-projectile vomiting, non-bilious and non-bloody. The symptoms waxed and waned and were worst at night. She also reported having anorexia, and unintentional weight loss but no pain related to meals (eating or fasting). Antacids gave partial relief to her epigastric pain. There was no abdominal distension related with her symptoms; her constipation was not absolute, as she was able to pass flatus. There was no alternation of the constipation with diarrhea and no melaena or haematochezia. Her other symptoms included borborygmi, lower back and bilateral knee pain. Patient was hypertensive and on amlodipine, no other medication. She had completed empirical triple therapy for peptic ulcer disease several years prior to this presentation, but without resolution of her occasional dyspeptic symptoms. There was no history of abdominal surgeries and she had never smoked nor consumed alcohol.Her physical examination showed mild pallor and moist mucous membranes. She was afebrile. Her abdomen was soft, non-distended, moved with respiration. There was generalized tenderness which was worst at her lower abdomen. There were no palpable masses, percussion notes were tympanitic and bowel sounds were high pitched and frequent. Both knees were mildly tender on passive joint movement (worse on the left) but not swollen or warm, and there was mild tenderness at her lower back. All other examination findings were normal.An initial diagnosis of acute exacerbation of Crohn disease with partial bowel obstruction and peptic ulcer disease was made. Differentials included a large bowel tumour (possibly left sided because of the obstructive symptoms) and osteoarthritis of both knees.Her renal and liver function tests were normal. She however had normocytic normochromic anaemia of 10.6g/dl on her complete blood count and low calcium and magnesium levels of 1.61mmol/L, 1.07mmol/L respectively. An erect and supine abdominal x-ray showed mildly dilated jejunum as well as gall stones. A contrast CT scan of the abdomen showed mild to moderate narrowing of the mid segment of the ileum with enhancing mucosa and prestenotic dilatation of the ileum and jejunum. The dilated bowel measured 3.8cm-4.5cm. There were no masses seen and the large bowel was normal. It also confirmed the presence of the gall stones. Both ESR and CRP were high (30mm/h and 147 respectively). Stool RE was normal and stool for occult blood and H. pylori antigen were negative.A final diagnosis of acute exacerbation of Crohn disease with partial bowel obstruction and gastritis was made. Complications of the condition noted were cholelithiasis, arthritis of both knees and sacroiliitis. Her calculated Crohn Disease Activity Index (CDAI) was 263; for moderate disease. She was hydrated with IV fluids, then put on hyoscine bromide for her crampy abdominal pains, IV omeprazole for her gastritis, IV metronidazole, SC enoxaparin for DVT prophylaxis and syrup lactulose for her constipation. After her vomiting subsided, she was switched to oral medications. Oral mesalazine 1g 6 hourly, oral prednisolone 30mg daily and oral paracetamol 1g 8 hourly were added to her medications. She showed improvement as well as reduced frequency of the flares. She was on admission for 6 days before discharge with the following plan: review in a 2 weeks with a lower GI endoscopy, high fibre diet (with dietitian review), at least 3L of oral hydration daily, and compliance on her medications.DiscussionIntestinal obstruction caused by strictures of Crohn disease widens the differential diagnoses for clinicians. These include intraluminal causes such as tumours, impacted faeces and foreign bodies, intramural causes such as intussusception and extramural causes such as strangulated hernias, adhesions and volvulus.3-5 Most of these are purely surgical causes. It is no surprise the patient in question had to pass through the general surgery team first. It is quite unusual that she had never experienced diarrhea or had it alternate with her constipation. This is because it is expected that before the strictures form, the preceding and causal inflammation would irritate the intestinal tract enough to cause some diarrheal symptoms.6 The patient also had peptic ulcer-like symptoms which had been treated unsuccessfully in the past. Because of the rareness of dyspepsia as a symptom of Crohn disease,7 it is unlikely to be the marker to point to the accurate diagnosis. Evidently, this patient had been managed empirically for peptic ulcer disease for a long time. This is common practice because of the low availability of endoscopy in the Central Region of the country. Given her age and presentation, it was most likely she had IBD-related arthritis on an osteoarthritis of her knees. This is because there were flares with the joint pains as well; instances when she could experience excruciating pain even at rest. She required a walking aid because of this disabling pain. Abdominal pain in Crohn disease has several mechanisms8, and because of the transmural inflammatory pattern, tenderness on palpation is not a surprising finding, as was in this patient.Hypocalcaemia and hypomagnesemia as was seen in the patient is a common finding in Crohn disease due to fat malabsorption resulting in vitamin D deficiency, as well as anorexia caused by the abdominal pain and inflammatory cytokines.9 The malabsorption is also the reason for formation of gallstones as in this patient (figure 1 and figure 2). The gallstones form as a result of failed reabsorption of bile acid and hence failed enterohepatic circulation, which in turn increases the concentration of cholesterol in the biliary system, precipitating the formation of cholesterol stones.10It is usually asymptomatic and an incidental finding on radio imaging.Starting the patient on prednisolone and mesalazine resulted in a decline in symptoms by the 5th day of admission. 5-aminosalicylic acid derivatives such as mesalazine provide symptomatic relief for patients and remain the first line drugs for mild to moderate disease.11 It was effective in this patient as well, as she was ready for discharge by admission day 6. Lactulose also improved her constipation by enabling her pass soft stools daily.ConclusionCrohn disease should not be expected to manifest as abdominal pain with diarrhea all the time. Its extra-intestinal manifestations as well as its capacity to affect any part of the gastrointestinal tract requires that every clinician have a high suspicion index for its diagnosis. Common presentations such as gastritis and intestinal obstruction need to be well-investigated with less complacency in order to ensure accurate causal diagnosis is made all the time.Competing interestsNone declared.ReferencesCard TR, Siffledeen J, Fleming, KM. Are IBD patients more likely to have a prior diagnosis of irritable bowel syndrome? Report of a case-control study in the General Practice Research Database. United European Gastroentrol J 2014 Dec; 2(6): 505-512. PMID: 25452846Cheema YA, Munir M, Zainab K, Ogedegbe OJ. An Atypical Presentation of Crohn’s Disease: A Case Report. Cureus. 2022 Sep; 14(9): e29431. PMID: 36299929Catena F, De Simone B, Coccolini F, Di Saverio S, Sartelli M, Ansaloni L. Bowel obstruction: a narrative review for all physicians. 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