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Tuesday, 3 December 2013

Colitis - Misdiagnosis and delay diagnosis

Colitis is defined as a condition of inflammation of the large intestine, including the colon, caecum and rectum.
Misdiagnosis and delay diagnosis
1. Delay diagnosis
According to the study by University Central Hospital, patients with ischaemic colitis often delay from admission to the correct diagnosis in 8 days on the average (range 2-15 days). The reasons for delayed diagnosis included suspicion of diverticulitis, Crohn's disease and bowel obstruction as well as poor general condition in one case because of which early colonoscopy was not done. It is concluded that in patients with abdominal pain, rectal bleeding and diarrhoea associated with typical clinical findings, ischaemic colitis should be suspected. This suspicion should be followed by early colonoscopy to detect the gangrenous form of the disease as early as possible(26).

2. Takayasu arteritis
Takayasu arteritis is a chronic inflammatory disease that primarily affects large arteries such as the aorta and its proximal branches. The association between Takayasu arteritis and ulcerative colitis is an extremely rare condition. Herein we report a case of Takayasu arteritis who had been misdiagnosed and treated as ulcera, according to the study by Ankara Education and Research Hospital, Department of Nephrology(27). Other study also report a case of  a 17-year-old Chinese male developed upper limb sourness and a sensation of fatigue, and his upper limb pulses were absent. He was diagnosed with TA and underwent an axillary artery bypass with autologous great saphenous vein on the left subclavian artery. After the surgery, he regained the normal blood pressure. This patient also had years of diarrhea and developed an anal canal ulcer, and was diagnosed with inflammatory bowel disease and ulcerative colitis before. Five months after the TA surgery, he was hospitalized for severe stomachache and diarrhea and was finally diagnosed with Crohn's disease(28).

3. Schistosoma-related colitis
Schaumann bodies are inclusion bodies, first described by Schaumann in 1941, typically seen in granulomatous diseases such as tuberculosis, sarcoidosis and chronic beryllium diseases. Williams WJ, in 1964, reported Schaumann bodies to occur in 10% of Crohn's disease (CD). There is a report of a case of Crohn's disease, initially misdiagnosed as a schistosoma-related colitis for the presence of numerous calcified bodies resembling calcified ova and scattered granulomas. Subsequent biopsies showed more typical histological features and, in combination with a more complete clinical history, diagnosis of Crohn's disease was made, according to the study by A.O. Spedali Civili di Brescia, Brescia(29).

4. Others
Clinical parameters helpful in differentiating intestinal tuberculosis from Crohn's disease included chest radiographic features of tuberculosis (56% v 0%), perianal fistulae (0% v 40%) and extraintestinal manifestations of Crohn's disease (0% v 40%). Histopathological features that seemed to reliably differentiate between intestinal tuberculosis and Crohn's disease included confluent granulomas, > or =10 granulomas per biopsy site and caseous necrosis (in biopsy samples of 50%, 33% and 22% of patients with intestinal tuberculosis, respectively, v 0% of patients with Crohn's disease). Features that were observed more often in patients with intestinal tuberculosis than in those with Crohn's disease included granulomas exceeding 0.05 mm(2) (67% v 8%), ulcers lined by conglomerate epithelioid histiocytes (61% v 8%) and disproportionate submucosal inflammation (67% v 10%), according to the study by University of Cape Town(30).
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Sources
(26) http://www.ncbi.nlm.nih.gov/pubmed/1759791
(27) http://www.ncbi.nlm.nih.gov/pubmed/23311124
(28) http://www.ncbi.nlm.nih.gov/pubmed/19650203
(29) http://www.ncbi.nlm.nih.gov/pubmed/22503169
(30) http://www.ncbi.nlm.nih.gov/pubmed/16873564