SHM Converge Scientific Abstract ePoster Gallery-Beyond the Block: Navigating Diagnostic Overlap in a Case of Colonic Stricture

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This case highlights a diagnostic pitfall in a 61-year-old man with recurrent abdominal pain, constipation, and imaging suggestive of a Crohn’s-related fibrostenotic stricture near the ileocecal valve. At an outside hospital, CT/MRI showed small bowel obstruction with terminal ileitis and fat stranding. Colonoscopy found an ileocecal valve ulcer, a non-traversable terminal ileal stricture, and a 5 cm descending colon polyp with high-grade dysplasia. Biopsies were interpreted as inflammatory, and he was treated as Crohn’s disease with steroids.<br /><br />When he re-presented to Barnes-Jewish Hospital, inflammatory markers and labs were normal, and repeat CT/MR enterography again suggested a chronic stricture. Surgery was recommended for presumed medically refractory Crohn’s disease. However, operative findings revealed an obstructing ileocecal mass with peritoneal carcinomatosis. Pathology showed invasive poorly differentiated adenocarcinoma with nodal and peritoneal metastases.<br /><br />The case emphasizes that imaging can miss malignancy when cancer overlaps with benign strictures or chronic inflammatory changes. Risk factors such as older age, tobacco and alcohol use, lack of prior colon cancer screening, and especially a markedly elevated CEA (241) should have increased suspicion for malignancy. The patient also lacked many classic Crohn’s features, including bloody diarrhea, malabsorption, elevated ESR/CRP, and extraintestinal manifestations.<br /><br />Key lessons include avoiding diagnostic anchoring, reassessing the probability of alternate diagnoses, and communicating early with consultants. Biopsy remains essential, but strictures can limit endoscopic sampling and obscure underlying cancer. In stricturing inflammatory bowel disease, guidelines support early surgical consideration, particularly when dysplasia is present, because neoplasia may be hidden within or proximal to the stricture.

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Dallin Merrell

Meta Tag

Author List Dallin Merrell, Kevin S. Naceanceno, Randy Laine

Category Clinical Vignettes

Concept Colon Malignancy

Concept Ileocecal Malignancy

Concept Crohn Disease

Concept Fibrostenotic Stricture

Concept Biopsy

Distinguished Non-Finalist

Presenter Organization Washington University in St. Louis School of Medicine

Presenting Author Dallin Merrell

Track Adult

Keywords

ileocecal mass

Crohn's disease mimic

fibrostenotic stricture

terminal ileitis

poorly differentiated adenocarcinoma

peritoneal carcinomatosis

elevated CEA

diagnostic pitfall

bowel obstruction

colonic dysplasia

Colon Malignancy

Ileocecal Malignancy

Crohn Disease

Fibrostenotic Stricture

Biopsy