Introduction: Inflammatory bowel diseases are heterogeneous in their presentation. Crohn's disease (CD) has been described as an unusual cause of massive lower gastrointestinal bleeding. We present a patient with CD whose first presentation was hemoperitoneum following mild blunt abdominal trauma Case presentation: A 54-year-old woman came to the emergency room with a blunt abdominal trauma. The patient underwent an abdominal CT scan with i.v. contrast medium injection, which showed hemoperitoneum with stenotic strictures of the small bowel and active massive bleeding from ileocolic artery. The rapid anemia onset and the CT report induced us to perform blood transfusion and an emergency exploratory laparotomy. Histological examination of the resected terminal ileum revealed a Crohn's disease. Discussion: Crohn's disease has been associated with hemoperitoneum, but to date there is no exact protocol regarding treatment of massive hemorrhagic Crohn's disease, which is rare. A conservative approach with medical therapy has been suggested for initial treatment. However, if medical treatment fails or bleeding continues even with intervention, bowel resection through surgical therapy should be performed

AGRUSA, Antonino

DI BUONO, Giuseppe

GALFANO, Maria Cristina

GULOTTA, Gaspare

LO RE, Giuseppe

Midiri, F

ROMANO, Giorgio

VERNUCCIO, Federica

Archivio istituzionale della ricerca - Università di Palermo

HEMOPERITONEUM FOLLOWING MILD BLUNT ABDOMINAL TRAUMA: FIRST PRESENTATIONOF CROHN’S DISEASEAGRUSA ANTONINO1, ROMANO GIORGIO1, LO RE GIUSEPPE2, DI BUONO GIUSEPPE1, VERNUCCIO FEDERICA2, GALFANO MARIACRISTINA2, MIDIRI FEDERICO2, GULOTTA GASPARE11Department of General Surgery, Urgency and Organ Transplantation, University Hospital P. Giaccone, University of Palermo -2Department of Radiology, DIBIMEF, University Hospital P. Giaccone, University of Palermo ItalyIntroductionInflammatory bowel diseases (IBD) are idio-pathic chronic diseases of the gastrointestinal tractwell known to be associated with both genetic andenvironmental risk factors and with larger diffusionin Western countries. Although the exact aetiologyof IBD has still not been exactly identified, it isbelieve that the pathogenesis of IBD includesimmune deregulation secondary to environmentalfactors in genetically susceptible individuals.Modern studies report also a role of particular pro-tein, like chaperonins, in the activation of theimmune system leading to inflammation(1). Someepidemiological studies have already identified theincreasing global incidence and prevalence of IBDin developing countries as these countries becomemore developed and “Westernised”, highlightingthe significance of environmental factors on influ-encing IBD development globally. Currently, onlysmoking is an established risk factor for Crohn'sdisease (CD). There seems to be a dose-responserelationship between smoking and IBD and child-hood exposure to tobacco smoke is associated witha higher risk of developing CD. Oral contraceptivepill increases the risk of IBD too. Regarding diet,the literature is inconsistent and no clear dietaryrisk factors for IBD can be determined. IBD areheterogeneous in their presentation. The most fre-quent symptoms are chronic diarrhea with bloodand/or mucus, recurrent abdominal pains or dis-comfort, melena, weight loss, and/or perianal fistulaor abscess. CD is diagnosed if we find at endoscopyskip lesions, a cobblestone appearance, mucosalActa Medica Mediterranea, 2014, 30: 315ABSTRACTIntroduction: Inflammatory bowel diseases are heterogeneous in their presentation. Crohn’s disease (CD) has been describedas an unusual cause of massive lower gastrointestinal bleeding. We present a patient with CD whose first presentation was hemoperi-toneum following mild blunt abdominal traumaCase presentation: A 54-year-old woman came to the emergency room with a blunt abdominal trauma. The patient underwentan abdominal CT scan with i.v. contrast medium injection, which showed hemoperitoneum with stenotic strictures of the small boweland active massive bleeding from ileocolic artery. The rapid anemia onset and the CT report induced us to perform blood transfusionand an emergency exploratory laparotomy. Histological examination of the resected terminal ileum revealed a Crohn's disease.Discussion: Crohn’s disease has been associated with hemoperitoneum, but to date there is no exact protocol regarding treat-ment of massive hemorrhagic Crohn’s disease, which is rare. A conservative approach with medical therapy has been suggested forinitial treatment. However, if medical treatment fails or bleeding continues even with intervention, bowel resection through surgicaltherapy should be performed.Key words: Crohn’s disease, hemoperitoneum, emergency surgery , blunt abdominal trauma, CT scan.Received January 18, 2014; Accepted January 24, 2014ulceration and/or aphthous lesions. Extraintestinalmanifestations include musculoskeletal (sacroilitisand peripheral arthritis), mucocutaneous (erythemanodosum, pyoderma gangrenosum, aphthous stom-atitis), hepatic (primary sclerosing cholangitis),ophthalmic (episcleritis, uveitis) and urinary tractinvolvements. CD has been described as an unusualcause of massive lower gastrointestinal bleedingoccurring only in 0.9 - 6% of patients(2, 3, 4). CD sig-nificantly alters endothelial and vascular functionand this contributes to uncontrolled vascular-depen-dent intestinal damage(5, 6). This is a hallmark ofactive gut disease and is closely related to diseaseseverity.  We present a patient with CD whose first pre-sentation was hemoperitoneum following mildblunt abdominal trauma.Case presentationA 54-year-old woman came to the emergencyroom with a blunt abdominal trauma. On arrival shecomplained of worsening abdominal pain. On phys-ical examination she was slightly pale: heart rate88/min and blood pressure of 100/50 mmHg.Abdominal examination revealed tympanic bowelsounds in the lower abdominal quadrants withoutsigns of peritonitis. Routine blood test showed Hb12.6 g/dl; RBC 4.48 x 106 with increasing of mark-ers of inflammation (WBC 15.23 x 103; Neutrophilcount 90.2%; C-reactive Protein 87 mg/l). She hada medical history of appendectomy, removal ofovarian cyst and temporo-parietal meningiomaexcision.The patient underwent an abdominal CT scanwith i.v. contrast medium injection, which showedhemoperitoneum: in particular, blood effusionassumed a triangular shape as it insinuated betweensmall bowel loops. Moreover, on CT it was notablethe presence of stenotic strictures of the smallbowel, with increased mucosal enhancement,mesenteric inflammatory stranding and mesentericadenopathy. These signs were typical features ofCD patients that we could analyze in clinical rou-tine (e.g. use of the computed tomography enterog-raphy in evaluation of CD activity)(7) (Figure 1). Inthis clinical case the CT showed also, in portal andlate phases, tortuous mesenteric arteries, with sus-pect extravasation from the ileocolic artery. On thebasis of these findings, we suggested a diagnosis ofhemoperitoneum due to the rupture of a branch ofileocolic artery in a patient with CD (Figure 2). So, the patient was admitted to the SurgeryDepartment. Heart rate and blood pressure werenormal but the control blood test showed us a sig-nificant decline in hemoglobin (Hb 6.8 g/dl vs 12.6g/dl; WBC 12 x 103; Neutrophil count 85.8%; C-reactive Protein 95 mg/l). In other patients withhemoperitoneum or abdominal trauma we used suc-cessfully laparoscopic approach in emergency set-ting(8), but in this case the rapid anemia, the devel-opment of severe hypotension and the CT report(hemoperitoneum due to the rupture of a branch ofileocolic artery) induced us to perform blood trans-fusion and an emergency exploratory laparotomy(9)without any else study for cardiac or anesthesiolog-ic risk stratification(10). At laparotomy it was clear the presence ofblood effusion with clots and full-thickness mesen-teric tear with active bleeding from ileocolic ves-sels. Moreover, it was found that a considerablelength (30 cm proximal to the ileocecal valve) ofthe distal small bowel loops was thickened andshowed interloop adhesions with edematous mesen-tery, as it appears in IBDs. Considering both thehemoperitoneum and the findings suggestive forIBD, the patient underwent a right hemicolectomyextended to the distal ileum (40 cm) and ileo-trans-verse mechanical termino-lateral anastomosis. The316 Agrusa Antonino, Romano Giorgio et AlFig. 1: a) 3D VR MDCT reconstruction shows the smallwall thickening and strictures of the terminal ileum andthe mesenteric bleeding. b)  coronal reconstructionshows the bleeding from a branch of mesenteric ileocolicvein.Fig. 2: MDCT axial scan in arterial (a) and venous (b)phases shows the progressive mesenteric bleeding from abranch of mesenteric ileocolic vein.specimen was then analyzed by an experiencedpathologist. Macroscopic evaluation showed thatileal loops were adhering firmly to each other for alength of 32 cm; on the surface there was a focalhemorrhagic area. The mesentery was thickenedand its surface was irregular and brownish. Onopening the specimen, there was narrowing of thedownstream lumen for a length of 12 cm andbowel-wall thickening characteristic of CD. Themucosa was diffusely eroded showing the charac-teristic cobblestone appearance up to the ileocecalvalve, for a length of 22 cm.Histological examination of the resected ter-minal ileum revealed areas of denuded mucosa andinflammatory cell infiltration and lymphoid aggre-gates in the lamina propria and, sometimes, in thesubmucosa. The mesenteric lymph nodes showedreactive hyperplasia (Figure 3). DiscussionAcute gastrointestinal hemorrhage is a rarepresentation of CD(2, 3, 4). CD alters endothelial andvascular function and this contributes to uncon-trolled vascular-dependent intestinal damage(5, 6, 11).As recently proved by Kohoutova et al.(6) acquiredhypercoagulable abnormalities in IBD patients arefrequent. Funayama et al.(12) reported significantatrophy in the media of the submucosal peripheralarteries in patients suffering from ileal CD. As stat-ed by Cromer et al.(5), many inflammatory growthfactors, cytokines and chemokines mediate angio-genesis in IBD: the newly formed endothelium andthe inflamed vessels differs from the normal ones inthe production of and response to inflammatorycytokines, growth factors, and adhesion molecules,altering coagulant capacity, barrier function andblood cell recruitment in injury. Modern studiesreport also a role of particular protein, like chaper-onins, in the activation of the immune system. Thisis a hallmark of active gut disease and is closelyrelated to disease severity. Since 1970 CD has beenassociated to hemoperitoneum(13), but to date thereis no exact protocol regarding treatment of massivehemorrhagic CD, which is rare occurrence(14).A conservative approach with medical therapyhas been suggested for initial treatment(15).However, if medical treatment fails or bleedingcontinues even with intervention, bowel resectionthrough surgical therapy should be performed(16).Our patient had never complained symptoms ofIBD and this was her first presentation, followingblunt abdominal trauma. CT scan prompted a provi-sional diagnosis of CD and blood examinations withrapid anemia due to massive hemorrhage induced usto the decision of emergency laparotomy.The presence of CD in patients presenting likeours, with obvious trauma and absence of othersymptoms, is unlikely to be suspected and diagno-sis could only be made after CT scan, laparotomyand histology(17, 18). Moreover, Brownstein(19) report-ed the case of an acute small bowel obstructionoccurring five months after blunt abdominal trau-ma, in which the histopathology of the affected seg-ment of ileum was found to closely resemble CD.Burak et al.(20) reported also a case of suspected CDat laparoscopy, not confirmed at enteroscopy, in awoman with recurrent attacks of abdominal painfollowing minor abdominal trauma, and whose finaldiagnosis was C1 inhibitor deficiency.These findings highlight the difficulty in thediagnosis of CD in case of abdominal trauma. In our patient, the presence of an inflamededematous mesentery and tortuous mesenteric arter-ies as complications of undiagnosed and untreatedCD made her prone to hemorrhage. References1) Rodolico V, Tomasello G, Zerilli M, Martorana A,Pitruzzella A, Gammazza AM, David S, Zummo G,Damiani P, Accomando S, Conway de Macario E,Macario AJ, Cappello F: Hsp60 and Hsp10 increase incolon mucosa of Crohn’s disease and ulcerative colitis.Cell Stress Chaperones. 2010 Nov; 15(6): 877-84.2) Cirocco W.C., Reilly J.C., Rusin L.C. Life-threateninghaemorrhage and exsanguination from Crohn’s dis-ease. Report of four cases. Dis Colon Rectum. 1995;38: 85-95.3) Driver C.P., Anderson D.N., Keenan R.A. Massiveintestinal bleeding in association with Crohn’s disease.J R Coll Surg Edinb. 1996; 41: 152-154.Hemoperitoneum following mild blunt abdominal trauma: first presentation of Crohn’s disease 317Fig. 3: a-b) EE 4x, areas of disepithelization of the colo-nic mucosa; c-d) EE 10x, inflammation in the laminapropria extending focally into the submucosa with infil-trate of lymphocytes, neutrophil and eosinophil granu-locyte.4) Majeed MU, Jameel M, Williams DT Massive per rec-tal bleeding following blunt abdominal trauma: Firstpresentation of Crohn’s disease. Int J Surg Case Rep.2011; 2(7): 230-231.5) Cromer WE, Mathis JM, Granger DN, Chaitanya GV,Alexander JS. Role of the endothelium in inflammatorybowel diseases. World J Gastroenterol. 2011 Feb 7;17(5): 578-93.6) Kohoutova D, Pecka M, Cihak M, Cyrany J, Maly J,Bures J. Prevalence of hypercoagulable disorders ininflammatory bowel disease. Scand J Gastroenterol.2013 Dec 16. [Epub ahead of print]7) Lo Re G, Cappello M, Tudisca C, Galia M, RandazzoC, Craxì A, Cammà C, Giovagnoni A, Midiri M. CTenterography as a powerful tool for the evaluation ofinflammatory activity in Crohn's disease: relationshipof CT findings with CDAI and acute-phase reactants.Radiol Med. 2014 Jan. [Epub ahead of print].8) Agrusa A, Romano G, De Vita G, Frazzetta G,Chianetta D, Di Buono G, Gulotta G. Adrenal gunshotwound: Laparoscopic approach. Report of a case. Int JSurg Case Rep. 2014; 5(2): 70-2.9) Perino A, Proto E, Calagna G, Granese R, Agrusa A,Guarneri F, Cucinella G: Spontaneous rupture ofsplenic artery aneurysm in pregnancy: is splenectomyalways necessary? Acta Obstet Gynecol Scand. 2012Nov; 91(11): 1349-50.10) Novo G, Corrado E, Tortorici E, Novo A, Agrusa A,Saladino V, Marturana I, Lentini R, Ferrandes M,Visconti C, Massenti F, D’Arienzo M, Vitale F, GulottaG, Novo S. Cardiac risk stratification in elective non-cardiac surgery: role of NT-proBNP. Int Angiol. 2011Jun; 30(3): 242-6.11) Leonetti D, Reimund JM, Tesse A, Viennot S, MartinezMC, Bretagne AL, Andriantsitohaina R. Circulatingmicroparticles from Crohn’s disease patients causeendothelial and vascular dysfunctions. PLoS One. 2013Sep 3; 8(9): e73088. doi: 10.1371/journal.pone.0073088.12) Funayama Y, Sasaki I, Naito H, Fukushima K, MatsunoS, Masuda T. Remodeling of Vascular Wall in Crohn'sDisease. Dig Dis Sci. 1999 Nov; 44(11): 2319-23.13) McCullough FS, Ruppert RD, Greenberger NJ.Recurrent Hemoperitoneum. An Unusual Complicationof Regional Enteritis Arch Intern Med. 1970; 126(3):514-6.14) Iiritano E, Grassia R, Staiano T, Buffoli F. Life-threat-ening jejunal hemorrhage as first presentation ofCrohn’s disease. Inflamm Bowel Dis. 2010; 16: 1277-1278.15) Kazama Y, Watanabe T, Akahane M, Yoshioka N,Ohtomo K, Nagawa H. Crohn’s disease with life-threat-ening hemorrhage from terminal ileum: successful con-trol by superselective arterial embolization . JGastroenterol. 2005; 40: 1155-1157.16) Agrusa A, Romano G, Di Buono G, Dafnomili A,Gulotta G. Laparoscopic approach in abdominal emer-gencies: a 5-year experience at a single center. G Chir.2012; 33(11-12): 400-3.17) Lo Re G, Galia M, Bartolotta TV, Runza G, Taibbi A,Lagalla R, De Maria M, Midiri M. Forty-slice MDCTenteroclysis: evaluation after oral administration ofisotonic solution in Crohn’s disease. Radiol Med. 2007;112(6): 787-97.18) Romano G, Agrusa A, Frazzetta G, De Vita G,Chianetta D, Di Buono G, Amato G, Gulotta G:Laparoscopic drainage of liver abscess: case reportand literature review. G Chir. 2013 May-Jun; 34(5-6):180-2.19) Brownstein EG. Blunt abdominal trauma simulatingCrohn’s disease of the terminal ileum. Aust N Z J Surg.1984; 54(3): 287-9.20) Burak KW, May GR. C1 inhibitor deficiency andangioedema of the small intestine masquerading asCrohn’s disease. Can J Gastroenterol. 2000 Apr; 14(4):349-451._________Request reprints from:ANTONINO AGRUSADepartment of General Surgery, Urgencyand Organ Transplantation, University Hospital P. Giaccone,University of PalermoVia L. Giuffrè 590127 Palermo(Italy)318 Agrusa Antonino, Romano Giorgio et Al

Hemoperitoneum following mild blunt abdominal trauma: First presentation of Crohn's disease

https://iris.unipa.it/retrieve/handle/10447/97633/129336/HEMOPERITONEUM%20FOLLOWING%20MILD%20BLUNT%20ABDOMINAL%20TRAUMA%20FIRST%20PRESENTATION.pdf

Hemoperitoneum following mild blunt abdominal trauma: First presentation of Crohn's disease

Abstract

Similar works

Full text

Available Versions

Archivio istituzionale della ricerca - Università di Palermo