1. Ozturk, Omer MD
  2. Koklu, Seyfettin MD
  3. Basar, Omer MD
  4. Purnak, Tugrul MD
  5. Yuksel, Osman MD

Article Content

A 24-year man was admitted with a history of abdominal pain and weight loss for 6 months. He had a history of Celiac disease since childhood. Laboratory findings showed an anemia and elevated leukocyte count, sedimentation rate, and fecal calprotectin level. Upper endoscopy showed normal findings, and colonoscopy showed an ulcerated and vegetant mass that almost completely filled the lumen of the ascending colon (Figure 1). The mass did not allow the endoscopist to pass through the cecum. Multiple biopsy samples were taken from the mass. Three days after colonoscopy, he was admitted to the emergency department with vomiting and severe right lower quadrant abdominal pain. At physical examination, he had abdominal rebound and defense. Computed tomographic scan revealed a mass that filled the terminal ileum and cecum lumen with adjacent lymphadenopathies (Figure 2). The patient underwent emergency surgery, and right hemicolectomy was performed. Histological examination was compatible with Crohn disease (CD). He was given azathioprine and mesalazine, and was well during the 10-month follow-up period.

Figure 1 - Click to enlarge in new windowFIGURE 1. Endoscopic appearance of the inflammatory mass.
Figure 2 - Click to enlarge in new windowFIGURE 2. Abdominal tomographic scan demonstrating the total occlusion at the ascending colon and cecum by mass.


Crohn disease is an idiopathic, chronic inflammatory disorder. Symptomatic relapse and remissions occur during the course of the disease (Thoreson & Cullen, 2007). It is characterized by patchy involvement of the whole intestinal wall (Lichtenstein, 2000). Thus, CD can lead to deep ulcers and these ulcers can locate transversely and longitudinally over an inflamed mucosa with a cobblestone appearance (Kornbluth, Sachar, & Salomon, 1998; Thoreson & Cullen, 2007). Crohn disease can be seen in any part of the gastrointestinal tract from the mouth to the anus. However, CD mostly involves the ileum and colon (45% in the ileum and colon, 20% only in the colon, 33% only in the small bowel, and 5% in the other regions). Approximately 20% of patients have perianal complications such as fissures, fistulae, and abscesses (Wilkins, Jarvis, & Patel, 2011).


Crohn disease is an immunological disease, and chronic inflammation from T-cell activation causes tissue injury (Kornbluth et al., 1998; Thoreson & Cullen, 2007). The exact etiology of CD remains unknown. Many causes including genetic, microbial, immunological, environmental, dietary, vascular, and psychosocial factors have been reported. Interaction between the predisposing factors and triggering event may lead to appearance of the disease (Lichtenstein, 2000; Thoreson & Cullen, 2007).


The patient's clinical presentation typically includes abdominal pain, diarrhea, and finding of complications such as obstruction, fistulization, abscess, and anal ulcer or stricture or fissure (Panes et al., 2007). Transmural inflammation may cause thickening of the bowel wall and narrowing of the bowel lumen; consequently, this condition may lead to obstruction or deep ulceration, abscesses formation, or fistulization. Also, obstruction may occur by significant edema and inflammation of the mucosa. This kind of obstruction is usually intermittent and often reverses with anti-inflammatory agents. If obstruction does not improve with medical therapy, the disease shows progression and the obstruction becomes chronic causing further problems including fibrotic scarring, luminal narrowing, or stricture formation (Lichtenstein, 2000; Panes et al., 2007).


Most patients are treated by medical therapy; however, some need surgery during the course of the disease. Recently, use of biological anti-tumor necrosis factor (anti-TNF) agents (e.g., adalimumab, infliximab, certolizumab, and natalizumab) has significantly changed the treatment and reduced the need for surgery. The patients who present with complications such as intestinal obstruction, perforations, abscess, and fistula formations may require surgical intervention (Ford et al., 2011; Lichtenstein, 2000). Before the surgery, tuberculosis, malignancy, and ischemic intestinal diseases should be excluded in differential diagnosis (Gupta, Goyal, & Goyal, 2011; Katsanos et al., 2010). Endoscopic appearance and obstruction of the colon in the present case were highly suggestive of a malignant disease (Katsanos et al., 2010). Liatsos et al. (2010) presented a patient with CD with an inflammatory polypoid mass at the ileocecal valve. Because that patient did not have acute abdomen, they treated the patient with anti-TNF agent.



Crohn disease is a chronic inflammatory disorder. Because of the clinical heterogeneity at presentation, initial diagnosis may be difficult. Patients may present with complications of the disease. Treatment should be started immediately after performing differential diagnosis, and potent anti-inflammatory agents should be initiated.




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