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Dr. Amarsinha Nikam’s Chronic Case Quiz for Feb 2013 – Crohn’s Disease

Can you solve this case? Send your solution, including the rubrics you used, to: [email protected]

This is a case of a young lady all the way from Jalna, aged 20. When she came for treatment her condition was bad. She had a distended abdomen with a thin stream-lined body. It seemed to be a severe problem. During consultation, I learned that she was suffering with this problem for the last year. She mentioned that initially, she was suffering with abdominal pain only during menses, but later severity increased.

She underwent U.S.G., but reports did not reveal much. Her haematological tests reports were not satisfactory, especially Hb% which was very low, i.e. 7 gm%. Accordingly she underwent 3 blood-transfusions. Meanwhile, she was treated with high doses of painkillers; which didn’t give her any relief.

She continued complaining about darkness of skin and severe backache with distended abdomen. She had lost approximately 5-6 kg of her weight, which was clearly noticeable from her emaciated extremities.

She felt breathlessness because of distended abdomen. Bloated feeling with rumbling due to flatulence and pain was present day and night.

She underwent C.T. Scan and endoscopy as advised by gastroenterologist which revealed a mass, but it didn’t confirm any diagnosis. She then underwent diagnostic biopsy. It revealed the diagnosis of “Crohn’s Disease”.

Crohn’s disease was found at a developed stage for which modern science was left with no remedy.

She consulted on 16th Dec. 2007.

Crohn’s Disease : It is one of the major forms of Inflammatory Bowel Disease with a prevalence of 50-60 / 100,000 with a peak incidence between 20 & 40 yrs. Aetiology is unknown, but the racial difference & geographical clustering suggest both genetic & environmental causes. There are no HLA markers but HLA – B27 is increased in patients with Inflammatory Bowel Disease. Crohn’s Disease is a Chronic Inflammatory condition that may affect any part of the GIT from the mouth to the anus, but has a particular tendency to affect the terminal ileum. The disease can involve one small area of the gut or skip lesions. It may also be extensive, involving the whole of the colon / small bowel. The involved bowel loop is thickened and narrowed. Inflammation extends through all layers of the bowel.

Modern Science suggests immuno-supressive agents, steroids for this disease with dietary supplementation. Approximately 80% of patients will require an operation at some time during the course of their disease, yet a recurrence of about 15% per year is almost inevitable and most deaths are associated with surgery.

28.09.2007 : Barium Meal Study :

Multiple long stricture involving ileum and distal portion of jejunum with segmental dilatation and loss of normal mucosa fold; highly favor of Crohn’s disease, rather than Koch’s Abdomen.

Other reports not brought

Her complaints were:

< Rice. > Flatulence after.

< Overeating. > Warm Application.

> Rubbing over back.

> Lying on back.

Backache since2 months

Location : It was over spine, starting from lower lumbo-sacral region and going upwards up to cervical spine with stiffness sensation of neck.

A/f Post Operative.

< Menses before. > Rubbing over back.

< Abdomen pain during. > 2nd day of menses.

< Sitting prolong.

Blackish discoloration of skin :9 months.

Weight loss from 40 kg to 35 kg within last 2-3 months. (More marked over extremities.)

< Cold air. > Pressure.

> Tight Bandaging.

Position : lies on sides.

< Before menses. > 2nd day of menses.

In general > Open air.

  1. Let me know about your childhood?

I was born and brought up in Jalna. We were 5 people in family with one elder brother. I was the only girl child and hence pampered by family members who had made me aggressive and irritable in nature. I was very passionate about the things which I want. I was average in studies and good in drawing. But, I fear to be alone. I am an Arts Graduate and pursued ‘Diploma in Fashion Designing’ for a year.

  1. Tell me something about your married life?

I am newly married, just couple of months back. Since I was not feeling well from months back, my husband and mother-in-law felt that I have a serious disease and they started avoiding me. Later on, whole family started isolating me. I was not permitted to enter in kitchen and even our beds were separated.

Nowadays, I am staying with my parents, no communication with my in-laws; however I feel that some or the other day, they will accept me when I get cured.

  1. What about your nature?

As I previously mentioned I am very obstinate in nature; I get angry very soon if someone contradicts to my statement. Moreover my attitude is to remain silent and do not will to mingle with people. If someone talks rudely, I get hurt and start crying.

Her parents added that she very often gets violent and bangs her head on the wall; or not eat food. With a smile, her father added that once she was demanding a particular thing, but due to lack of money, we opposed and she went on a fast for 2 days. In addition, father stated that she feels embarrassed when she is insulted. She continues with her anger, remains silent for longer time and takes time to calm down.

  1. What type of tensions did you face previously?

I hardly face tension regarding my studies, rest all things were normal.

Nowadays there are somewhat tensions regarding my in-laws’ behavior.

  1. What makes you afraid?

I am scared of monkeys, of darkness and to be alone.

End

Can you solve this case? Send you solution, including the rubrics you used, to: [email protected]