A Pseudo-Tumoral Form of Crohn’s Disease in an Elderly Patient

Nacer, S.^1*, Haddad, F.¹, Mahtal, H.¹, El Rhaoussi, F. Z.¹, Tahiri, M.¹, Hliwa, W.¹, Bellabah, A.¹, Badre, W.¹, El Hattabi, K.^2,3, Choukri, E. M.^2,3, Bouali, M.^2,3, El Bakouri, A.^2,3, Bensardi, F. Z.^2,3 & Fadil, A.^2,3

¹Department of Gastro-Enterology and Proctology, UHC Ibn Rochd Casablanca, North Africa
²Department of Digestive Surgery, UHC Ibn Rochd Casablanca, North Africa
³Department of Digestive Surgical Emergencies, UHC Ibn Rochd Casablanca, North Africa

*Correspondence to: Dr. Nacer, S., Department of Gastro-Enterology and Proctology, UHC Ibn Rochd Casablanca, North Africa.

Copyright © 2022 Dr. Nacer, S., et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Introduction
Crohn’s disease is a chronic inflammatory condition that affects the gastrointestinal tract. Inflammation may occur at any point from the mouth to anus [1]. Crohn’s disease is rare in the elderly over 60 years. Its incidence is estimated at 3.5/100,000 [2]. Pseudotumoral forms are exceptional [3]. A neoplasia must be eliminated in front of a colonic tumor before retaining the diagnosis [4]. We report a case of colonic Crohn’s disease in its pseudotumoral form in an elderly patient.

Observation
A 80 years-old female patient with a medical history of diabetes mellitus type 2, chronic arterial hypertension presented to the emergency department with a one week history of intermittent pain in her right iliac fossa which had worsened over 3 days. There was associated with vomiting and chronic constipation with deterioration in general condition. She denied any rectal bleeding, fevers, or chills. There was no family history of colonic malignancies.

On physical examination, she was haemodynamically stable: pulse 76 beats/m, blood pressure 114/76mmHg, and body temperature 37C°. Abdominal examination found a tenderness in the right iliac fossa and a painful 5cm soft mass. Biological findings revealed a biological inflammatory syndrome: white cell count of 11420/ mm3 and C-reactive protein of 112. Other haematology and biochemical parameters were unremarkable.

A computed tomography (CT) abdomino-pelvic scan with contrast showed an irregular collection of the right iliac fossa measuring 77X56mm with infiltration of mesenteric fat. Emergency laparotomy revealed the presence of a non stenosing tumor in the cæcum measuring 8cm in diameter invading the posterior abdominal wall clogging a purulent collection. Ileocecal resection and a right hemicolectomy were performed followed by an ileocolostomy.

The histopathological examination of the resected specimen showed chronic inflammatory changes with an epithelioid and gigantocellular granuloma without caseous necrosis. Absence of histological signs of malignancy.

Postoperative period was uneventful.

Colonoscopy performed later, revealed multiple circumferential ulcers measuring between 08 and 12 mm from which biopsy specimens were obtained. The mucosa between the ulcers was normal. The histopathological examination found epithelioid granulomas and basal plasmacytosis with mucin preservation in the epithelium. Magnetic resonance (MR) enterography showed a marked concentric, symmetric and regular thickening of many ileal loops.

Diagnosis of Crohn’s disease was made.

The patient was treated with systemic corticosteroids at the dose of 1mg/kg for six weeks with degression and azathioprine at the dose of 2mg/kg with a favorable outcome.

Discussion
Crohn’s disease is a chronic inflammatory disease of the gastrointestinal tract with symptoms evolving in a relapsing and remitting manner [5,6]. All segments of the gastrointestinal tract can be affected, the most common being the terminal ileum and colon [5]. About 25-35% of the inflammatory bowel disease (IBD) population is over the age of 60 years, of whom about 15% have been diagnosed relatively late in life [7] like our patient. Presenting symptoms can be heterogeneous and insidious [5]. Some elderly patients may have atypical presentations of their disease [7].

The pseudotumoral form remains exceptional [3] and has been reported in the literature only in eight publications. The main differential diagnosis is malignant intestinal pathology especially since the IBD of the elderly seems to be associated with increased risk of malignancies, particularly colitis-associated colorectal cancer and malignant lymphoproliferative disorders [8,9].

Its clinical presentation is variable: abdominal mass as our patient and the case reported by Stoica et al. [10], obstruction like the nine cases reported by Fekih and al [3] or pseudo-obstruction [2-4,11]. Other authors have reported bloody diarrhea and weight loss [12], rectal bleeding [13] and constipation [14].

The abdomino‐pelvic CT scan performed was not contributory to the diagnosis of the pseudotumoral form as it fail to differentiate it from colonic neoplasia.

In fact, and like in our case, all the sixteen patients in the series of Fekih and et al. [3], the eight patients in the series of Tamzaourte and et al. [11] and the patient of Bouomrani et al. [2] underwent surgery and the diagnosis was made on pathological examination of the operating specimen. Anatomopathological examination eliminated the diagnosis of cancer in the absence of tumor cells.

The detection of gigantocellular epithelioid granulomas without caseous necrosis associated with inflammatory reaction, should be discussed sarcoidosis, a foreign body reaction, or parasitosis [14].

In this case, the combination of clinical, radiological and histological elements confirmed the diagnosis of crohn’s disease.

Evolution with specific treatments (azathioprine and corticosteroids), marked by the regression of symptoms comforted the diagnosis. The same observations have been made in the literature [12-14].

Conclusion
Pseudotumoral form of crohn’s disease is a rare entity that appears to have its own clinical and morphological features. The diagnosis seems to be difficult especially in elderly because it can mimic a colonic cancer. Histopathological examination remains the basis of the diagnosis.

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