Indian J Pediatr DOI 10.1007/s12098-015-1793-4

SCIENTIFIC LETTER

Isolated Jejunal Crohn’s Disease in an Adolescent Girl B. Bhaskar Raju 1 & Sumathi Bavanandam 2 & Anand Thiagarajan 3 & Nandhini Ganapathy 4

Received: 19 October 2014 / Accepted: 13 May 2015 # Dr. K C Chaudhuri Foundation 2015

To the Editor : We report an adolescent girl with isolated jejunal stricture due to Crohn’s disease (CD) diagnosed at laparotomy. A 16-y-old girl, with a body mass index of 12.9 kg/m2, presented with symptoms of partial small bowel obstruction, loose stools and weight loss for 2 mo. On examination, she was pale, with mild abdominal distension. There were no extraintestinal manifestations of inflammatory bowel disease. Differential diagnosis were tuberculosis, gastrointestinal lymphoma, ileal Crohn’s disease and eosinophilic enteritis. Investigation revealed iron deficiency microcytic hypochromic anemia (Hb 10.5 g/dl), thrombocytosis (platelet count 5,70000 cells/cu mm), hypoalbuminemia (S. albumin 2.8 g/dl) and raised Serum C-reactive protein (78 mg/L). Fecal occult blood, Mantoux and retroviral tests were negative. Upper and lower endoscopy with biopsy were normal. Computed tomography of abdomen (CECT) showed dilatation of proximal jejunal loops with mural thickening (Fig. 1). As patient did not respond to supportive treatment, she underwent laparotomy which confirmed a one foot jejunal

Fig. 1 CT abdomen showing mural thickening with significant focal thickening of small bowel (jejunum)

stricture (Fig. 2), with creeping mesenteric fat. Rest of the gut was normal. The strictured segment was resected with an end to end anastomosis of the jejunum. Histopathology of the specimen and mesenteric nodes was consistent with Crohn’s disease (Fig. 3). Patient has been on follow up for more than 2 y, is asymptomatic and is being maintained on azathioprine in dose of 2 mg/kg.

* Sumathi Bavanandam [email protected] 1

Department of Pediatric Gastroenterology, Dr. Mehtas Children’s Pvt. Ltd, Mc Nichols Road, Chetpet, Chennai, Tamil Nadu, India

2

Institute of Child Health & Hospital for Children, Chennai, Tamil Nadu 600008, India

3

Department of Radiology, Dr. Mehta’s Children Hospitals Pvt. Ltd, Mc Nichols Road, Chetpet, Chennai, Tamil Nadu, India

4

Department of Pediatric Surgery, Dr. Mehta’s Children Hospitals Pvt. Ltd, Mc Nichols Road, Chetpet, Chennai, Tamil Nadu, India

Fig. 2 Resected segment of jejunum showing luminal narrowing

Indian J Pediatr

Deep fissuring ulcers extending into muscularis propria

Inflammatory cell infiltration

Non caseating granuloma

Fig. 3 Histopathology of resected segment showing extensive transmural inflammation, nodular lymphoid aggregates, mucosa with fissuring ulcers extending into muscularis propria lined by

inflammatory granulation tissue, histiocytes, surrounded by fibroplastic reaction and small non caseating granulomas

Crohn’s disease has bimodal age distribution and isolated jejunal involvement represents approximately 1 % of cases in adults [1]. In a recent multicentre epidemiology study on CD in Indian children, the mean age of presentation for CD was 11.02±4.5 y. The predominant clinical presentation was abdominal pain (73.8 %), growth retardation/nutritional impairment (76.2 %), fever (39.3 %), anemia (69.9 %) and diarrhea (48.4 %). Ileo-colon (72.9 %) was the most common site; almost a third (27 %) had fistulae, perianal abscess, stricture and perforation; 6.5 % had an obstructive stricture [2]. Small bowel stricture occurs in 20 % with typical presentation similar to our case [3, 4]. Isolated jejunal Crohn’s disease is rare and may present just with hypoalbuminemia and fever or weight loss of unknown etiology, often requiring laparotomy for diagnosis. CECT and / or MR enterography is useful in small bowel stricture; capsule enteroscope, though ideal is contraindicated [5]. Resection is recommended when stricturoplasty fails. This was not opted in our patient. Mesalamine and azathioprine, given post operatively reduces relapse and stricture recurrence rates.

Conflict of Interest None. Source of Funding None.

References 1.

Lonardo A, Tondelli E, Selmi I, et al. Isolated jejunal Crohn’s disease in a young adult presenting as fever of unknown origin. Am J Gastroenterol. 1998;93:2285–7. 2. Sathiyasekaran M, Bavanandam S, Sankaranarayanan S, et al. Questionairre survey of pediatric inflammatory bowel disease in India. Indian J Gastroenterol. 2014;33:543–9. 3. Tan WC, Allan RN. Diffuse jejunoileitis of Crohn’s disease. Gut. 1993;34:1374–8. 4. Cooke WT, Swan HJ. Diffuse jejuno-ileitis of Crohn’s disease. Q J Med. 1974;43:583–601. 5. Buchman AL, Miller FH, Wallin A, et al. Videocapsule endoscopy versus barium contrast studies for the diagnosis of Crohn’s disease recurrence involving the small intestine. Am J Gastroenterol. 2004;99:2171–7.