1. Department of Gastroenterology
PROBLEM CASE
A Case of Small Bowel Ulcer with Laryngeal Ulcer in 38-Year-Old Man
Department of Gastroenterology

2. 박O준 M/38 입원일 2005.01.08 2nd Admission Chief complaint : Hemoptysis
- onset : 6 hours ago
Present illness 년 10월경부터 abdominal pain 호소하여 개인병원 에서 capsule endoscopy 시행 후 Crohn’s disease 진단 하에 PO Medication 해 오던 환자로 내원 당일 1L 정도의 hemoptysis를 지속 적으로 하는 증상을 주소로 응급실 경유하여 호흡기 내과로 입원 - 내원 약 1개월전부터 sore throat, hoarseness 호소하여 내원 하루전 ENT 외래에서 laryngeal Crohn’s disease 의심하에 1월 11일 larynx biopsy 예정되어 있었음

3. Past medical history DM (-) HTN (-) Tb (-) Hepatitis (-) - small bowel segmental resection due to ulcer perforation
Family history None
Personal history Alcohol (-) Smoking (-)
Current drug history Mesalazine / Prednisolone

4. Review of Systems
General : fatigue (+) fever (+) chills (-) night sweat (-) weight loss (+) -7kg for 2 months
Skin : rash (-) itching (-) pigmentation (-)
Head / Neck : headache (-) hoarseness (+) sore thraot (+)
Respiratory : cough (-) sputum (+) dyspnea (-) haemoptysis (+) cyanosis (-)
Cardiac : orthopnea (-) chest pain (-) palpitation (-)
GI : A/N/V/D/C (-/-/-/-/-) haematochezia (-) melena (-) abdominal pain (-)

5. Physical Examination
Vital sign 110/70 mmHg – 108/min – 22/min – 38.3 °C
General appearance - Alert mentality - Acutely ill appearance
Skin - No rash or pigmentation
Head & Neck - No cervical / supraclavicular lymph node enlargement - Neck vein engorgement (-)

6. Eyes and ENT - Isocoric pupils with pupilary light reflex (++/++) - Whitish sclera - Pale conjunctivae
Chest - Clear breath sounds without crackle or wheezing - Regular heart beats without murmur
Abdomen - Soft and flat abdomen - Normoactive bowel soud - No tenderness or rebound tenderness - No palpable abdominal mass

7. Back and Extremities - CVA tenderness ( - / - ) - Pretibial pitting edema ( - / - )
Neurology - Unremarkable

8. Initial Lab Results
CBC/DC 3,800/mm3 – 11.8 g/dL– 21.4 % - 113K/mm3 (Seg 55.5%, Lymph 38.8%, Mono 3.4%, Eosino 0.1%)
Chemisrty TB/DB 2.4/1.3 mg/dL ALP 670 U/L GGT 118 U/L Prot/Alb 6.4/2.6 g/dl AST/ALT 98/187 U/L LD 912 U/L Ca/P 8.3/3.2 mg/dl Bun/Cr 23/0.7 mg/dl Na/K/Cl 141/3.7/107 mmol/L ESR 14mm/hr CRP 1.9 mg/dL
Urinalysis RBC 0~1/ HPF WBC 0~1/ HPF

9. Chest X-ray

10. Initial Problem Lists Hemoptysis Fever Crohn’s disease, known
Hyperbilirubinemia with elevated liver enzyme level

11. Initial Assessment
Crohn’s disease with laryngeal ulcer bleeding with or without aspiration pneumonia
Abnormal liver function due to unknown cause due to viral hepatitis R/O Cholestasis

12. Initial Work-up Plan CBC F/U Chest X-ray F/U
Sputum culture with AFB stain, Gram stain
Blood culture
Bronchoscopy
Biopsy of larynx
LFT F/U
Hepatitis viral marker
Abdominal US

13. Bronchoscopy –

14. Laryngeal biopsy –
Brochoscopic Biopsy Necrosis and a few of lymphoid cells

15. Neck and Chest CT I

16. Neck and Chest CT II

17. Clinical course I
Hemoptysis due to laryngeal ulcer Result from laryngeal manifestation of Crohn’s disease - Ceftriaxone / Clindamycin - Mesalazine(Pentasa) / PDL - persistent fever (38.0~39.0°C)  Blood aspiration pneumonia or Crohn’s disease ?
Abnormal LFT : Not yet identified - F/U TB/DB 1.5/0.8 mg/dL AST/ALT 69/121 U/L - Abdominal US ; Mild fatty liver with splenomegaly
Refer to dep. of GI for management of Crohn’s disease

18. Previous Colonoscopic Finding 2004-12-13

19. Small Bowel Series

20. Clinical Course II
No haemoptysis or other bleeding  Discharge
Re-admission to GS due to abdominal pain - Recurrent small bowel perforation - Neck subcutaneous emphysema due to larynx perforation
Small bowel segmental resection (ileum)
Tracheostomy due to laryngeal perforation - Rebiopsy of larynx

21. Clinical Course Review
Crohn’s disease initial diagnosis [한솔병원]
st small bowel perforation [GS]
– Hemoptysis [Pulmo]
– Transfer to GI
– 2nd small bowel perforation [GS]

22. NK/T cell Lymphoma, nasal type
Laryngeal biopsy II
CD3+
NK/T cell Lymphoma, nasal type

23. Review of Previous Small Bowel Pathology (2004.11.18)
CD56+
NK/T cell Lymphoma, nasal type

24. Clinical relationship with NK/T cell lymphoma
Splenomegaly
Weight loss ; - 7Kg for recent 2 months
Persistent fever
Elevation of bilirubin, AST, ALT level ?

25. Final Diagnosis
Extranodal NK/T cell Lymphoma, with Larynx and Intestine Involvement