Answer: Crohn’s disease

Histology: The endoscopic photo reveals aphthoid ulcers. Histological sections did not demonstrate the ulcers, a not uncommon finding given the focality of the ulcers.

The biopsy shows mild patchy active inflammation with cryptitis and crypt abscesses. In areas, the inflammation also appears granulomatous (Image 4). A mild increase in chronic inflammation is also seen.

Discussion: While the changes are mild and etiologically non-specific, the patchy distribution and sparing of the sigmoid and rectum are consistent with the diagnosis of Crohn’s disease, a diagnosis confirmed by subsequent clinical and histological follow-up. The aphthoid ulcers seen in this case are similar to those that can be seen in oral phospho-soda bowel preparations (see case 5 of this week’s conference). It is important to remember, however, that similar ulcers are not typically seen in phospho-soda enema (Fleet enema). In sum, an aphthoid ulcer is not necessarily diagnostic of Crohn’s disease especially if a patient has been prepped with oral phospho-soda.

This case also illustrates the importance of endoscopic correlation, as again the aphthoid ulcers were not demonstrated histologically.

Acute self-limited colitis is also in the differential, but the changes of chronicity noted elsewhere in the colon (see history), suggest a long-standing process. The principal features of enema effect are absent and enema-induced changes are largely limited to the rectum and lower sigmoid.