S4951 Small Bowel Crohn's Disease Diagnosed on Exploratory Laparotomy

Introduction: Crohn’s disease is a type of inflammatory bowel disorder that can present with a wide constellation of symptoms. We present a case of penetrating small bowel Crohn’s disease diagnosed post small bowel resection for retrieval of retained video capsule. Case Description/Methods: A 64-year-old woman with chronic constipation presented with iron deficiency anemia and 50 lb weight loss over 2 years. Colonoscopy showed moderate diverticula, TI was not intubated, and no biopsies were collected. Esophagogastroduodenoscopy was unremarkable, and H. pylori negative. Video endoscopy showed a small ulceration in the jejunum with capsule retention in terminal ileum after 8 hrs. Stool calprotectin 522 mcg/g, after video capsule retention. Computed tomography AP showed mesenteric lymphadenopathy with a 2.1 cm lesion and thickening of the small bowel loops. A follow up positron emission tomography scan showed mildly increased FDG avidity. Because of concern for malignancy, the patient underwent laparoscopic resection of the mesenteric lesion, with intraoperative findings of lumpiness of the liver and mid- small bowel and creeping fat in the nearby small bowel. Pathology revealed benign fibroadipose and lymphoid tissues. At this point, double- balloon enteroscopy was attempted for capsule retrieval, which was unsuccessful due to tethering and fixation of the bowel. A computed tomography enterography revealed focal narrowing of distal jejunum/proximal ileum, submucosal edema, mucosal hyperenhancement with sparing of terminal ileum. Colorectal surgery was consulted, and intra-operatively found a forming fistula in the pelvis to the vaginal vault/bladder, and a 25 cm segment of small bowel with thickened mesentery and multiple strictures. Small intestine pathology was consistent with Crohn’s disease. Post-operatively the patient was started on infliximab (5 mg/kg) induction and is now maintained on infliximab. Discussion: We present a case of penetrating ileal Crohn’s disease diagnosed after small bowel resection despite normal esophagogastroduodenoscopy and colonoscopy. This case highlights the need to evaluate small bowel Crohn’s disease with imaging in the setting of ongoing clinical symptoms and intraoperative findings, such as creeping fat, elevated stool calprotectin, and retained video capsule endoscopy.