Análise comparativa de dois volumes diferentes de agente de contraste oral para enterografia por tomografia computadorizada em pacientes com doença de Crohn / Comparative analysis of two oral contrast agent volumes for computed tomography enterography in crohn's disease patients

ABSTRACT BACKGROUND: Crohn's disease (CD) is an inflammatory bowel disease characterized by a chronic and recurrent inflammation of the gastrointestinal tract caused by an interaction of genetic and environmental factors. OBJECTIVE: To compare the quality and acceptance of two different oral contrast volumes for computed tomography enterography in Crohn's disease patients. METHODS: A cross-sectional study was conducted in 58 consecutive Crohn's disease patients who randomly received an oral contrast agent composed of 78.75 g polyethylene glycol diluted in either 1,000 mL or 2,000 mL of water. An examination was performed to evaluate the presence of inflammation or complications in the small bowel. The variables included the quality of intestinal segment filling and luminal distension, and oral contrast agent acceptance and tolerance in the patients. Statistical analysis included descriptive statistics and association tests. RESULTS: A total of 58 patients were assessed, in which 58.6% were female, 34.5% exhibited clinically-active disease, and 63.8% were receiving biologic therapy. As for comparative analysis between the two different volumes of oral contrast, no statistically significant difference was found regarding bowel loop filling (P=0.58) and adequate luminal distension (P=0.45). Patients who received a larger volume (2,000 mL) exhibited side-effects more frequently (51.7% vs 31.0%; P=0.06) and had greater difficulty ingesting the agent (65.5% vs 37.9%; P=0.07) compared with a volume of 1,000 mL. CONCLUSION: The quality of computed tomography enterography was not influenced by the contrast volume. However, acceptance and tolerance were better in the 1,000 mL group.

RESUMO CONTEXTO: A doença de Crohn (DC) é uma doença inflamatória intestinal caracterizada por uma inflamação crônica e recorrente do trato gastrointestinal causada por uma interação de fatores genéticos e ambientais. OBJETIVO: Comparar a qualidade e aceitação de dois volumes diferentes de contraste oral para enterografia por tomografia computadorizada em pacientes com doença de Crohn. MÉTODOS: Um estudo transversal foi conduzido em 58 pacientes com doença de Crohn que receberam aleatoriamente um agente de contraste oral composto por 78,75 g de polietilenoglicol diluído em 1.000 mL ou 2.000 mL de água. Um exame foi realizado para avaliar a presença de inflamação ou complicações no intestino delgado. As variáveis incluíram a qualidade do preenchimento do segmento intestinal e distensão luminal e aceitação e tolerância do contraste oral nos pacientes. A análise estatística incluiu estatística descritiva e testes de associação. RESULTADOS: Foram avaliados 58 pacientes, dos quais 58,6% eram mulheres, 34,5% apresentavam doença clinicamente ativa e 63,8% estavam recebendo terapia biológica. Quanto à análise comparativa entre os dois diferentes volumes de contraste oral, não foi encontrada diferença estatisticamente significativa em relação ao enchimento da alça intestinal (P=0,58) e distensão luminal adequada (P=0,45). Pacientes que receberam um volume maior (2.000 mL) exibiram efeitos colaterais com mais frequência (51,7% vs 31,0%; P=0,06) e tiveram maior dificuldade para ingerir o agente (65,5% vs 37,9%; P=0,07) em comparação com um volume de 1.000 mL. CONCLUSÃO: A qualidade da entero-tomografia computadorizada não foi influenciada pelo volume de contraste. No entanto, aceitação e tolerância foram melhores no grupo de 1.000 mL.

Perfil clínico-epidemiológico da tuberculose intestinal em pacientes de um hospital universitário / Clinical and epidemiological profile of intestinal tuberculosis in patients of a university hospital

OBJETIVO: Estabelecer o perfil clínico-epidemiológico da tuberculose intestinal em pacientes assistidos em um ambulatório específico. MÉTODOS: Estudo descritivo e retrospectivo, no qual foram avaliadas as principais características da população com diagnóstico de tuberculose intestinal atendida em um hospital universitário e notificada de janeiro 2009 a junho de 2017. RESULTADOS: A população foi constituída na maioria por mulheres, com média de 47,7 anos, negativas para o anti-HIV e residentes na região metropolitana. Ao diagnóstico, 27,3% apresentavam alteração de hábito intestinal e 45,4% doença fistulizante/ estenosante. Quase todos os resultados do PPD foram positivos, e 100% das radiografias de tórax não possuíam anormalidades. No histopatológico do segmento intestinal, o achado mais prevalente foi o granuloma caseoso. CONCLUSÃO: A tuberculose deve ser investigada em pacientes com doença intestinal no nosso país. (AU)

epidemiological profile of intestinal tuberculosis in patients assisted in a specific outpatient clinic. METHODS: This was a descriptive and retrospective study evaluating the main characteristics of the population with diagnosis of Intestinal tuberculosis treated at a University Hospital, and notified from January 2009 to June 2017. RESULTS: The population consisted mostly of women, with a mean age of 47.7 years, negative for anti-HIV, and livingin the metropolitan region of the city. At diagnosis, 27.3% presented changed bowel habits, and 45.4% fistulizing/stenosing disease. Almost all PPD results were positive and 100% of chest radiographs had no abnormalities. In the histopathology of the intestinal segment, the most prevalent finding was caseous granuloma. CONCLUSION: Tuberculosis should be investigated in patients with intestinal disease in our country. (AU)

Comparison of conventional and structured report in the evaluation of Crohn's disease through enterography / Comparação entre laudo convencional e estruturado na avaliação da Doença de Crohn por enterografia

ABSTRACT Context: There is an increasing interest in the standardization of the evaluation of imaging exams, especially enterography in Crohn's disease. Objective: To compare the quality of the conventional report with the structured report in computed tomography enterography in Crohn's disease. Method: Nine CT enterographies of patients with Crohn's disease with conventional reports were performed; after the standardization of the structured report by the radiology department of a university hospital that is a reference in the care of patients with inflammatory bowel diseases, the same exams were reevaluated, and new reports were issued, without the radiologists having access to the previous report; the 18 reports underwent evaluation of five specialists in Inflammatory Bowel Diseases, resulting in 90 analyses of the report; the specialists evaluated the following criteria: clarity of the information of the report, ease in characterizing the extension of the disease, ease in defining the presence of complications, usefulness of the exam to define the behavior, and ease in defining the activity of the disease, with the use of a 0-10 score. The statistical analysis was perfrmed with Wilcoxon's non-parametric test, considering a significance level of 5%. Results: The mean scores assigned to the exam reports, using both reports (unstructured and structured) ranged from 7.98 to 9.16; however, the scores of the structured reports were significantly higher (p < 0.003). Conclusion: In the specialists' evaluation, the structured report was shown to be of better quality than the unstructured one in the CT enterography of patients with Crohn's Disease.

RESUMO Contexto: Há cada vez maior interesse em padronização na avaliação de exames de imagem, em especial a enterografia na Doenca de Crohn. Objetivo: Comparar a qualidade do laudo convencional com o estruturado na enterografia por tomografia computadorizada na Doença de Crohn. Método: Foram realizados nove enterografias por TC de pacientes com Doença de Crohn com laudos convencionais; após a padronização do laudo estruturado pelo serviço de radiologia um hospital universitário, referência no atendimento de pacientes com doenças inflamatórias intestinais, os mesmos exames foram reavaliados e novos laudos foram emitidos, sem que os radiologistas tivessem acesso ao laudo anterior; os 18 laudos foram submetidos a avaliação de cinco especialistas em Doenças Inflamatórias Intestinais, resultando em 90 análises de laudo; os especialistas avaliaram os seguintes critérios: clareza das informações do laudo, facilidade em caracterizar a extensão da doença, facilidade em definir a presença de complicações, utilidade do exame para definir a conduta e facilidade em definir a atividade da doença, conferindo uma pontuação de 0 a 10. A análise estatística foi realizada com o teste não paramétrico de Wilcoxon, considerando-se nível de significância de 5%. Resultados: os escores médios atribuídos aos laudos do exame, usando ambos os relatórios (não estruturado e estruturado), variaram de 7,98 a 9,16; todavia, os escores dos laudos estruturados foram significativamente maiores (p < 0,003). Conclusão: Na avaliação dos especialistas o laudo estruturado mostrou-se de melhor qualidade que o não estruturado na enterografia por tomografia computadorizada de pacientes com Doença de Crohn.

Utilidad de la monitorización terapéutica de infliximab en el manejo de la enfermedad inflamatoria intestinal / Usefulness of therapeutic monitoring of infliximab in the treatment of inflammatory bowel disease

Background: Primary non-response and secondary loss of response (LOR) are significant problems of biological therapy for inflammatory bowel disease (IBD). Therapeutic drug monitoring (TDM) in IBD patients receiving these drugs can improve outcomes. Aim: To measure serum infliximab levels and anti-infliximab antibodies (ATI) in patients with IBD post-induction phase and during maintenance therapy assessing the clinical course of IBD. Patients and Methods: Prospective study of IBD patients receiving infliximab between July 2016-May 2017. Group-A included patients who received induction therapy while Group-B included patients who were in maintenance therapy. TDM was performed in serum samples collected at weeks-14 and 30 in Group-A and before the infliximab maintenance dose in Group-B. Clinical scores, fecal calprotectin and endoscopic score were also evaluated. Results: Of 14 patients in Group-A, 57% achieved endoscopic response. Median serum infliximab concentrations at week-14 and 30 were 2.65 AU/mL (0.23-32.58) and 2.3 AU/mL (0.3-16.8), respectively. Patients with mucosal healing had non-significantly higher median infliximab concentrations at week- 14, as compared to week 30 (median 3.2 vs 2.2 AU/ml, respectively, p 0.6). ATI >10 ug/mL were found in one and seven patients at week-14 and 30, respectively. At 52 weeks of follow-up, four patients (31%) had LOR. Group-B included 36 patients, 33% had LOR. Median serum concentrations of infliximab were 1.4 AU/mL (0.27-7.03). No significant differences in serum infliximab concentration were observed between patients in remission and those with inflammatory activity. Seventeen patients had ATI >10 ug/mL. Conclusions: Clinical algorithms using TDM might help to optimize the pharmacological therapy of IBD.

Papel da ultrassonografia endoscópica na avaliação da fístula perianal na doença de Crohn / Usefulness of endoscopic ultrasound for perianal fistula in Crohn's disease

RESUMO Objetivo: determinar o papel da ultrassonografia endoscópica (UE) em relação à ressonância magnética nuclear (RMN) e ao exame sob anestesia (ESA) no manejo de pacientes com doença de Crohn fistulizante perianal. Métodos: estudo observacional transversal com pacientes com doença de Crohn perianal, avaliados em um centro terciário de Curitiba, Paraná, Brasil, de fevereiro de 2016 a março de 2017. Todos os pacientes foram submetidos à UE, RMN e ESA. O grau de concordância entre os três métodos foi avaliado através da obtenção do coeficiente de Kappa. Um valor de Kappa de 0,7 ou maior indicou boa concordância. O teste não paramétrico de Friedman foi utilizado para comparar o número de trajetos fistulosos detectados em cada modalidade. Considerou-se o nível de significância estatística como p<0,05. Resultados: vinte pacientes foram incluídos. Houve concordância entre os três exames em 11 pacientes. O nível de concordância de Kappa entre os três exames foi 0,53 (moderado) (p<0,001). Não houve diferença estatisticamente significativa em relação ao número de trajetos fistulosos detectados nos três exames (p=0,641). Houve falha na identificação de um trajeto fistuloso em três pacientes com a UE, em três pacientes com a RMN e em dois pacientes com o ESA. Conclusão: a UE foi comparável à RMN e ao ESA para avaliação da doença de Crohn fistulizante perianal, e pode ser considerada um exame válido para investigação pré-operatória desses pacientes.

ABSTRACT Objective: to determine the role of endoscopic ultrasonography (EU) in comparison with nuclear magnetic resonance imaging (MRI) and examination under anesthesia (EUA) in the management of patients with perianal fistulizing Crohn's disease. Methods: we conducted a cross-sectional, observational study with patients with perianal Crohn's disease evaluated at a tertiary center in Curitiba, Paraná, Brazil, from February 2016 to March 2017. All patients underwent EU, MRI and EUA. We evaluated the degree of agreement between the three methods by obtaining the Kappa coefficient. A Kappa value of 0.7 or greater indicated good agreement. We used the Friedman's non-parametric test to compare the number of fistulous paths detected in each modality. We set the level of statistical significance at p<0.05. Results: we included 20 patients. There was agreement between the three exams in 11 patients. The level of Kappa agreement between the three exams was 0.53 (moderate - p<0.001). There was no statistically significant difference in relation to the number of fistulous trajectories detected in the three exams (p=0.641). EU failed to identify a fistulous pathway in three patients; MRI failed in three; and EUA failed in two. Conclusion: EU was comparable to MRI and EUA for the evaluation of perianal fistulizing Crohn's disease, and can be considered a valid exam for preoperative investigation of such patients.

Computed tomography enterography and magnetic resonance enterography in small intestine of Crohn's disease / Enterografia por tomografia computorizada e por ressonância magnética na avaliação da Doença de Crohn do intestino delgado

Abstract Crohn disease is defined as a chronic inflammatory and idiopathic process that can affect any portion of the gastrointestinal tract. The small intestine is the most frequently affected place, so small bowel morphology investigation is often mandatory.For decades small bowel was almost inaccessible to endoscopies, and, studies like enteroclysis and bowel transit time test, were considered gold standard tests. Recently, innovative imaging techniques, improved diagnosis and follow-up of Crohn disease patients by allowing the exploration of this gut segment.Authors review literature, concerning the role of computed tomography enterography and magnetic resonance enterography in the evaluation of small bowel Crohn disease.Authors conclude that the choice of examination to be made should be weighted considering several factors such as the age of the patient, their tolerability, the Crohn's disease phenotype and the availability of hospital resources.

Resumo A doença de Crohn é definida como um processo inflamatório e idiopático crônico que pode afetar qualquer parte do trato gastrintestinal. O intestino delgado é o local mais frequentemente afetado e, assim, com frequência torna-se obrigatória uma investigação da morfologia do intestino delgado.Durante décadas, o intestino delgado era praticamente inacessível às endoscopias; nesse contexto, estudos como a enteróclise e a determinação do tempo de trânsito intestinal eram considerados como os critérios diagnósticos principais. Recentemente, técnicas imaginológicas inovadoras aperfeiçoaram o diagnóstico e seguimento de pacientes com doença de Crohn, por permitirem a exploração desse segmento intestinal.Os autores revisam a literatura pertinente ao papel da enterografia por tomografia computadorizada e da enterografia por ressonância magnética na avaliação da doença de Crohn no intestino delgado.Os autores concluem que a escolha do exame a ser realizado deve levar em conta diversos fatores, como a idade do paciente, tolerabilidade, o fenótipo da doença de Crohn e a disponibilidade dos recursos hospitalares.

Paediatric inflammatory bowel disease: Clinical presentation and disease location

Objective: To determine different clinical presentations and disease location demarcated by upper and lower gastrointestinal endoscopy and relevant histopathology in children diagnosed with inflammatory bowel disease [IBD]

Methods: This is 5 years [2010 to 2015] retrospective study conducted at the Aga Khan University Hospital enrolling 65 admitted children between 6 months to 15 years from either gender, diagnosed with IBD on clinical presentation, endoscopy and biopsy. Different clinical presentations at the time of diagnosis were noted in different categories of the disease. All patients underwent upper and lower [up to the terminal ileum] endoscopy with multiple punch biopsies and histologic assessment of mucosal specimens. All endoscopies were done by paediatric gastroenterologists at endoscopy suite of the hospital and all specimens were reported by the pathology department. ESPGHAN revised criteria for the diagnosis of inflammatory bowel disease in children and an adolescent was used to standardize our diagnosis. Extent of disease on endoscopy and relevant histopathology of the biopsy samples were noted at the time of diagnosis. Data was summarized using mean, standard deviation, numbers and percentages for different variables

Results: Total 56 children were enrolled according to inclusion criteria. There were 34 children [61.53%]diagnosed with ulcerative colitis [UC] 10 patients [16.92%] had Crohn's Disease [CD] and 11 [21.53%] patients were labeled as Indeterminate colitis [1C]. Mean age at onset of symptoms was10.03+/-2.44 and mean age at diagnosis was11.10+/-2.36. Abdominal pain [80%] and chronic diarrhea [70%] were common symptoms in CD whereas bloody diarrhea [79.41%] and rectal bleeding [64.70%] were common presentation in UC. Patients diagnosed with indeterminate colitis [IC] had similar clinical features as in UC patients. Only 7% patients had some extra-intestinal features in the form of joint pain and /or uveitis. Aspartate aminotransferase level [95.18 +/-12.89] was relatively high in patients with CD in comparison with other categories of IBD. Endoscopic findings and relevant histopathology of biopsy samples in UC showed 65% patient had pan-colitis and 13% with disease restricted to rectum only whereas in CD 70% patient had| disease in ileo-colon and only 10% had involvement of ileum at the time diagnosis

Conclusion: Patients with UC dominated in our cohort. The most common clinical presentation in UCJ was bloody diarrhea and rectal bleeding and patients with CD had abdominal pain and chronic diarrhea i as predominant clinical features. Extraintestinal features were uncommon in our cohort. In endoscopicl findings, pan-colitis was the most frequent finding in UC and ileo-colon was common location in CD. 1C and UC shared common clinical features and disease location on endoscopy

Retención de cápsula endoscópica en un paciente con sospecha de enfermedad de Crohn / Endoscopic capsule retention in a patient with clinical suspicion of Crohn's disease

The endoscopic capsule is classically used in the study of occult bleeding, but has recently been shown to be useful in the diagnosis and follow-up of Crohn's disease. The retention of the capsule is the most frequent complication related to its use. We report the case of a 30-year-old male patient with recurrent abdominal pain and suspected Crohn's disease. A procedure with a video endoscopic capsule was performed; twelve hours after its ingestion, the patient goes to the emergency department due to worsening of the pain. Abdominal and pelvic CT demonstrates multiple areas of segmental parietal thickening of the ileum and a metallic foreign body in an area of stenosis corresponding to the retained endoscopic capsule. It evolves with persistent pain despite pharmacological therapy. Subsequently it is extracted by enteroscopy. The indications and risks of the use of the endoscopic video capsule, and the clinical and imaging factors predictive of retention are discussed.

La video cápsula endoscópica se utiliza clásicamente en el estudio de sangrado oculto, pero últimamente se ha demostrado su utilidad en el diagnóstico y seguimiento de la enfermedad de Crohn. La retención de la cápsula es la complicación más frecuente relacionada a su uso. Se presenta el caso de un paciente de sexo masculino de 30 años con dolor abdominal recurrente y sospecha de enfermedad de Crohn. Dentro del estudio se le realiza una video cápsula endoscópica; doce horas posteriores a su ingesta consulta en el servicio de urgencia por empeoramiento del dolor. La tomografía computada de abdomen y pelvis demuestra múltiples áreas de engrosamiento parietal segmentarias del íleon y un cuerpo extraño metálico en un área de estenosis, correspondiente a la cápsula endoscópica retenida. Evoluciona con persistencia del dolor pese a la terapia farmacológica. Posteriormente se procede a su extracción mediante enteroscopia. Se discuten las indicaciones y riesgos del uso de la video cápsula endoscópica, y los factores clínicos e imagenológicos predictores de retención.

Modalidades de imagen en la evaluación de enfermedad inflamatoria intestinal / Imaging techniques in the evaluation of inflammatory bowel disease

La enfermedad inflamatoria intestinal es una patología crónica, con una incidencia cada vez mayor. Dentro de este grupo de afecciones, la enfermedad de Crohn y la colitis ulcerosa son las más frecuentes. La enterografía por tomografía computada (ETC) y por resonancia magnética (ERM) son las modalidades de elección para la evaluación y seguimiento de la entidad, permitiendo examinar la apariencia de la mucosa, la pared intestinal, las manifestaciones extraintestinales y las complicaciones asociadas. La elección del estudio debe hacerse de acuerdo con la condición clínica de cada paciente

Inflammatory bowel disease is a chronic condition with increasing incidence. Crohn's disease and ulcerative colitis are the most common pathologies. Computed tomography (CT) enterography and magnetic resonance (MR) enterography are the methods of choice for evaluating and monitoring this entity, assessing the appearance of intestinal wall, mucosa, extra-intestinal manifestations, and associated complications. The preferred imaging methods must be selected according to the clinical conditions of the patient

CT enterography in the evaluation of Crohn's disease / Enterografia por tomografia computadorizada na avaliação da doença de Crohn

Proposition: Crohn's disease (CD) is a chronic inflammatory process that affects various parts of the gastrointestinal tract, from the mouth to the anus with unknown etiology and variable clinical presentation. CD diagnosis is based on clinical and complementary tests. Among the complementary tests, enterography with CT enterography has shown good results in the evaluation of this disease. Methods: The patients evaluated were submitted to a questionnaire on the clinical manifestations of the disease and an CT enterography was obtained. The studies were reviewed by an experienced radiologist looking for radiological signs of CD. Results: The mean age was 40 years, with a predominance of women. The main clinical manifestations are diarrhea in 24 (70%), hematochezia in 19 (55%), abdominal pain in 29 (85%) and weight loss in 22 (64%) patients. The main findings on CT enterography were an intestinal wall enhancement signal in 23 patients (67%), vascular engorgement (vasa recta) in 20 (58%), parenteral fat densification in 14 (41%), intestinal wall thickening in 22 (64%), and lymph node enlargement in 17 (50%) of patients. Conclusion: This study showed that CT enterography presents a good assessment of intestinal involvement by CD. (AU)

Proposição: A doença de Crohn (DC) é um processo inflamatório crônico que acomete vários locais do trato gastrointestinal, desde a boca até o ânus, tendo etiologia desconhecida e apresentação clinica variável. Seu diagnóstico baseia- se no exame clínico e em testes complementares. Dentre os exames complementares, a Enterografia por Tomografia Computadorizada (Entero-TC) tem mostrado bons resultados na avaliação dessa doença. Metodologia: Os pacientes avaliados foram submetidos a um questionário sobre as manifestações clinicas da doença e realizaram Entero-TC. Esses exames foram analisados por um radiologista experiente, à procura de sinais radiológicos da DC. Resultados: A idade média foi de 40 anos, com predomínio de mulheres. As principais manifestações clínicas foram diarreia em 24 (70%), hematoquezia em 19 (55%), dor abdominal em 29 (85%) e perda de peso em 22 (64%) dos pacientes. Os principais achados na Entero-TC foram o sinal de realce de parede intestinal em 23 pacientes (67%), ingurgitamento vascular (vasa recta) em 20 (58%), densificação de gordura perientérica em 14 (41%), espessamento de parede intestinal em 22 (64%) e linfonodomegalia em 17 (50%) dos pacientes avaliados. Conclusão: O presente estudo mostrou que a Entero-TC apresenta boa avaliação do acometimento intestinal pela DC. (AU)

Cápsula endoscópica: quando indicar seu uso? / Endoscopic capsule: when to indicate its use?

Muito do diagnóstico e tratamento das patologias do intestino delgado tem sido discutido e estudado na última década, desde a introdução da cápsula endoscópica na prática médica. Esta importante inovação tecnológica possibilitou o rompimento da última fronteira endoscópica do trato digestivo, permitindo o acesso endoscópico a toda a extensão do intestino delgado, o qual, devido a suas peculiaridades anatômicas e extensão, permanecia acessível somente à enteroscopia intraoperatória.

Both diagnosis and treatment of small intestine pathology has been discussed and studied in last decade since the introduction of endoscocopy capsule in medical practice. This important technological innovation allowed to break the last endoscopy borderline of digestive tract permitting endoscopy access for all extent of small intestine which due its anatomical peculiarities and extent remained accessible only to intraoperative enteroscopy.

Distinguishing tuberculosis and crohn's disease in developing countries: How certain can you be of the diagnosis?

Distinguishing tuberculosis and Crohn's disease in patients presenting with chronic abdominal pain and diarrhea is a huge diagnostic challenge, particularly in tuberculosis endemic countries. A large number of patients with Crohn's disease are initially misclassified as having Intestinal tuberculosis in places where tuberculosis is endemic before they are treated for Crohn's disease. Although a variety of endoscopic, radiological and histological criteria have been recommended for the differentiation, it often proves difficult in routine clinical practice. Future prospective studies are required in patients with granulomatous colitis to prevent unnecessary inappropriate anti tuberculous therapy for patients with Crohn's disease and appropriate early treatment for a patient with tuberculosis

Primary hypertrophic osteoarthropathy accompanied by Crohn's disease: a case report

Primary hypertrophic osteoarthropathy is a rare hereditary disease without evidence of underlying diseases. We report a very unusual case of primary HOA accompanied by Crohn's disease with the primary HOA mimicking secondary HOA, which is a rare manifestation of Crohn's disease. We also review the literature to find the correlation, if any, between the two.