Unusual Crohn's - Forum

[Alalo]

I'd like to share an unusual case and gather your opinions.

A 73 y.o female presents to the E.R. a month ago with complaints of RLQ
pain, mild guarding, no rebound and a WBC of 11K. Before I got there, E.R.
had CT of abdomen which showed some retroperitoneal lymphadenopathy, some
thickening of the terminal ileum, and an inflammatory process [no abcess] in
a retrocecal appendix. She had experienced intermittent RLQ pain, nausea
and cramping for 2 weeks prior to presentation. Laparotomy via RLQ incision
revealed indurated retrocecal appendix with mild inflammation...mostly
fibrotic. Terminal ileum looked and felt ok and no meckel's. There was a 1
cm node in mesentery of appendix, but I felt no need to biopsy it because I
thought that she had retrocecal appendicitis.
She rapidly recovered and went home on P.O. day 2. Her path report
said she had a mucinous cystadenoma of appendix with chronic inflammation.
1 week later in P.O. follow up she was doing fine.
Within days of her last visit with me, she began experiencing
post-prandial nausea and vague abdominal pains. Loose stool, but not
diarrhea and no obvious blood. Her symptoms were significant enough to lose
8 pounds and she once again came to E.R. with a 2 gram drop in HB and fever
of 99.5, and hemoccult positive stools.
I thought she must have a p.o. abdominal hematoma, so I repeated her
C.T. Again it shows lymphadenopathy, no splenomegally, and nothing of
significance at the operative site. Upper G.I. with small bowel follow
through shows inflammation of terminal ileum typical of Crohns.
My next step will be colonoscopy with attempts to cannulate and biopsy
the terminal ileum..
What if I fail? Is extensive retroperitoneal lymphadenopathy {not
bulky} consistent with Crohns or should I suspect lymphoma? Should I be
concerned about cystadenocarcinoma? Should I treat empirically, or should
I get a tissue diagnosis with a laparotomy?
Sorry for the verbosity. As always, I appreciate your comments.

[Surgeon]

I would choose a midline incision in the presence of the mentioned
findings in CT scan.

May-be missing cystadenocarcinoma? Review the slides AND if there are
unexamined paraffin blocks. I have never seen one, and so have no
experience with it.

Mesenteric lymphadenopathy is typical, not retroperitoneal. There are
reports of lymphoma developing in cases of long-standing Crohn's of
small bowel.

If the lymphadenopathy is benign, you don't need the surgery. If it is
malignant and so extensive surgery won't help either. But you don't want
to miss a lymphoma. Any other more accessible lymph nodes? Hate to have
to reopen that belly again.