P4410 - Location, Location, Location: A Case of Small Bowel Stricturing in a Crohn's Disease Patient Unrelated to Crohn's Disease

Dhiraj K. Peddu, MD¹, Matthew Kubina, MD², Ankit Mishra, MD², Molly Stone, MD², Winnie Zou, MD², Jiaqi Shi, MD, PhD², David C. Kestenbaum, MD³, Scott E. Regenbogen, MD, MPH², Jeffrey A. Berinstein, MD^2
1University of Michigan, Ypsilanti, MI; ²University of Michigan, Ann Arbor, MI; ³Montefiore Medical Center, New Rochelle, NY

Introduction: Crohn’s disease (CD) is an autoimmune condition causing gastrointestinal inflammation, leading to complications like strictures, fistulas and abscess formation. While CD phenotype and severity can progress, the location of disease often remains stable. We present a patient with long-standing stricturing ileocolonic CD treated with ileocolic resection, who later developed new jejunal and ileal inflammation and stenosis.

Case Description/Methods: A 46-year-old female with long-standing short-segment ileal and colonic fibrostenotic CD on maintenance infliximab presented with abdominal pain and dyspnea. Five months prior to admission, she underwent ileocolic resection for treatment of her CD (margins without active disease) complicated by intraoperative duodenal injury. On admission to our hospital, CT chest demonstrated a large pulmonary embolism, ultimately requiring ICU care. She was started on IV methylprednisolone for active CD as CT enterography showed multifocal inflammation with a 40-50 cm distal jejunal stricture with proximal small bowel (SB) dilatation (Figure 1A-B). Despite re-induction with two doses of infliximab at 10 mg/kg, she showed no improvement. Colonoscopy demonstrated congestion and stenosis at the ileocolonic anastomosis. Biopsy of the neo-terminal ileum stricture revealed an ulcer with ischemic changes. Review of prior CTs revealed lack of distal superior mesenteric artery (SMA) enhancement (Figure 1C-D). Interventional radiology and vascular surgery were consulted; however, the lesion was felt to be not intervenable due to the distal location and time since initial injury. IV methylprednisolone and infliximab were discontinued with plans for surgical SB resection when medically optimized. Unfortunately, the patient developed septic shock secondary to aspiration pneumonia and later succumbed to her illness.

Discussion: In this case, review of prior imaging following ileocolic resection highlighted chronic SB hypoperfusion from the distal SMA. The patient most likely developed SMA thrombus resulting in ischemic enteritis and SB stenosis with thrombotic risk-factors of active inflammation, corticosteroid use, and recent surgery. Post-ischemic strictures are rare sequelae of ischemic bowel disease and can mimic diseases such as CD or malignancy due to overlapping clinical symptoms and histopathological findings. This case underscores the importance of re-evaluating the diagnosis when the presentation is atypical. 



Disclosures:


Dhiraj K. Peddu, MD¹, Matthew Kubina, MD², Ankit Mishra, MD², Molly Stone, MD², Winnie Zou, MD², Jiaqi Shi, MD, PhD², David C. Kestenbaum, MD³, Scott E. Regenbogen, MD, MPH², Jeffrey A. Berinstein, MD². P4410 - Location, Location, Location: A Case of Small Bowel Stricturing in a Crohn's Disease Patient Unrelated to Crohn's Disease, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.