Point of care ultrasound for evaluation and the follow-up of the Crohn's disease
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Brief clinical history: A 51-year-old woman with a history of consumption of 10 cigarettes / day, with irregular follow-up for Crohn's disease (CD), under treatment with azathioprine; who goes to the Emergency Department (ED) for diarrhea of 3 months of evolution, aggravated in the last month, with liquid stools without blood, abdominal pain, weight loss and occasional low-grade fever.
Misleading elements:
We present the case of a patient attended in the ED for severe outbreak of CD, complicated with malnutrition and Clostridiumdifficile infection. Point of care ultrasound (POCUS) performed by emergency physicians (EP) trained in this technique for CD is a non-invasive approach that can be used to initial evaluation in case of suspected CD, assessment of the extent of the disease, diagnosis of complications, determination of inflammatory activity and monitoring of medical treatment.We used a Sonosite M-Turbo, with convex probe C60e/5-2MHz.
Helpful details: On physical examination, hemodynamically stable, afebrile, with significant physical deterioration (weight: 38 kg), muco-cutaneous pallor and abdomen without alterations. Laboratory results showed:Hemoglobin of 11.4 g/dl with microcytosis, 12120 leukocytes/mm3, CRP 67 mg/dl. Microbiological studies: Clostridium difficile toxin positive, coproculture-negative parasites. A bedside ultrasound performed by the EPshowed transmural thickening of the terminal ileum, with narrowing of the lumen and decrease in peristalsis, involvement of the underlying mesenteric fat and multiple lymphadenopathies, all of which are compatible with an outbreak of CD. The diagnosis was confirmed by abdominal-pelvic computed tomography, detecting diffuse colitis in relation to exacerbation of CD, without significant extraintestinal complications. The patient was diagnosed with severe outbreak of CD, malnutrition and C. difficile infection. After starting treatment with nutritional supplements, intravenous corticosteroids and metronidazole with poor efficacy, vancomycin was prescribed and started infliximab therapy. After 6 weeks of admission and good symptomatic evolution, the patient was discharged from hospital.
Differential and actual diagnosis: Because of the segmental nature of CD, a variety of disorders can mimic the clinical presentation. These include diverticulitis, appendicitis, diverticular colitis, ischemic colitis, and a perforating or obstructing carcinoma. lymphoma, chronic ischemia, endometriosis, and carcinoid can all give a radiologic and clinical picture that is easily confused with CD of the small bowel.
Educational and/or clinical relevance:The diagnosis of a patient with CD is based on the combination of symptoms and clinical signs, laboratory tests, endoscopy and imaging techniques. Intestinal ultrasound due to its diagnostic accuracy and safety, has been postulated as the technique of choice in the evaluation and follow-up of CD. POCUS performed by EP trained in this technique, allows to determine the existence of inflammatory activity with the following ultrasound findings: increased thickness of the intestinal wall (> 3 mm for the small intestine), presence of mesenteric fat involvement, nodules lymphatic and hyperemia or blood flow in color Doppler. It also provides information on which segments are affected and possible complications, such as: stenosis, fistulas and transmural or intra-abdominal abscesses.
