Unusual Endoscopic Appearance of Crohn's Disease: Another Face of a Multifaceted Disease

To the Editor:

Crohn's disease (CD) is a clinically heterogeneous condition, with various clinical presentations in different patients. Endoscopic and transsectional radiological imaging remains the mainstay of evaluation and management of the disease. The most characteristic (“elementary”) endoscopic lesions of CD are pseudopolyp, healed ulceration, frank erythema, frankly swollen mucosa, aphthoid ulceration, superficial or swallow ulceration, deep ulceration, and nonulcerated or ulcerated stenosis.¹ Although the most frequently observed location of CD is the ileum and the right side of the colon, a solely cecal location with a tumor-like endoscopic feature has never been described in the literature.

A 27-year-old female was admitted to our clinic in September 2010 with 2 weeks history of right lower abdominal pain, nausea, and two loose stools daily. Her medical history was remarkable for an appendectomy in 2008. On physical examination mild ileocecal tenderness was observed. The laboratory findings showed a moderately elevated C-reactive protein level of 49.7 mg/L and erythrocyte sedimentation rate of 36 mm/h. Abdominal ultrasonography included wall thickening of the cecum with enlarged lymph nodes. The colonoscopy revealed an unusual polypoid lesion between the ileocecal valve and the appendiceal orifice which resembled a tumorous tissue (Fig. 1A,B). However, histology disclosed intramucosal lymphoid infiltration with nonnecrotizing epithelioid cell granulomas suggesting indolent B-cell lymphoma or sarcoidosis (Fig. 1C). The ileum and the other part of bowel were completely negative. Further histological examination excluded lymphoma and confirmed the presence of inflammatory process. Due to the patient's continuous abdominal complaints, the adjacent lymph nodes and the tumor-like endoscopic finding of the cecal lesion confirmed by a second endoscopy, laparoscopic right hemicolectomy was performed in January 2011. According to the surgeon's opinion, the macroscopic finding of the resected cecum seemed to be malignant. Surprisingly, the histological finding of the resected tissue revealed granulomatous fibrotizing colonic CD. Further examinations were performed to exclude other granulomatous diseases. Nasal endoscopy excluded Wegener granulomatosis; chest x-ray and quantiferon test did not confirm tuberculosis. Autoimmune markers and gastroscopy was negative. The revision of the tissue from the previous appendectomy did not reveal CD. On the basis of these data, we can conclude that the diagnosis is truly CD with an extremely rare appearance and location (solely to the cecum without the involvement of the ileocecal valve).

The diagnosis of CD requires the patients' history including symptoms, intestinal and extraintestinal complications, physical examination, laboratory tests, endoscopy, histology, and imaging methods if needed.² The endoscopic appearance of CD is highly variable and changes with disease activity and duration. Polypoid lesion of the cecum usually refers to colorectal malignancy, carcinoid, or tuberculosis (TB). Since CD and TB of the gastrointestinal tract are clinically and radiologically similar diseases, the differentiation of them is challenging for clinicians. Although the final diagnosis is based on histology, colonoscopy still plays an important role in establishing a suspected disorder. Only few studies compared the diagnostic value of endoscopy in CD and intestinal TB. One of them found that anorectal lesions, longitudinal ulcers, aphthous ulcers, and a cobblestone appearance are significantly more common in CD, and involvement of fewer than four segments, a patulous ileocecal valve, transverse ulcers, and pseudopolyps were more frequent in intestinal TB.³ The study of Makharia et al⁴ revealed that skip lesions of the colon (66% vs. 16.9%, P < 0.001), aphthous ulceration (54.7% vs. 13.2%, P < 0.001), linear ulceration (30.1% vs. 7.5%, P = 0.005), and superficial ulceration (50.9% vs. 16.9%, P < 0.001) were significantly more frequent in patients with CD compared to patients with intestinal TB. Cobblestoning of the colonic mucosa was only seen in CD (16.9% vs. 0%, P < 0.001). Nodularity of the colonic mucosa was significantly more common in patients with TB than in those with CD (49% vs. 24.5%, P = 0.01). According to this study, colonic involvement was significantly more common in CD than in TB; however, there was no difference in the ileal or ileocolonic locations. In our case, the endoscopic appearance of the cecum suggested most likely colonic tumor or intestinal TB and least likely CD, since none of the abovementioned diagnostic endoscopic findings were detected. Such an unusual macroscopic appearance of CD has not been published before.

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