Department of Gastroenterology CPC

Department of Gastroenterology CPC

1. CPC meeting -09/09/2016
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

2. CPC
09-09-2016
Prof. (Dr) Sandeep Nijhawan
Head of Department
Dr Gaurav Gupta
Associate Professor
Dr. Kumar Shwetanshu Narayan
DM resident
Deptt of Gastroenterology
SMS Medical College and Hospital, Jaipur
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

3. CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator
Department of Gastroenterology,
Sawai Man Singh Medical College
Hospital, Jaipur

4. Gastroenterology department
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

5. Gastroenterology dept started in 1991
DM course started in 2000
Till now total no of DM alumni are >40
Initially there were 2 DM seats per year
Since 2010, DM seats increased to 6 per year.
Presently, there are 18 residents in the department
everytime.
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

6. Faculty and Unit devision
•Total no of faculty members are 10
•We have 3 units
•Unit heads-
–S.prof (Dr) Sandeep Nijhawan (Unit I)
–S.Prof (Dr) Shyam Sundar Sharma (Unit II)
–S.Prof (Dr) Rupesh Pokharna (Unit III)
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

7. Unit Wise Faculty
Unit I Unit II Unit III
S. Prof. (Dr) Sandeep
Nijhawan
Asso. Prof. (Dr) Gaurav
Gupta
Asst. Prof. (Dr)Surendra
Sultania
Dr Hemendra Bhardwaj

S. Prof. (Dr) Shyam Sundar
Sharma
Prof. (Dr) Bharat Sapra
Asst. Prof. (Dr) Ashok
Jhajharia
S.Prof. (Dr) Rupesh
Pokharna
Asso. Prof. (Dr) Prachis
Ashdhir
Asst. Prof. (Dr) Mukesh Jain
Dr Rekha Vyas
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

8. •130 publications
•3 farooque abdullah sher-
e-kashmir award
•1 J. M. Mitra national
endoscopy award
•6 national awards for best
paper
•Indigenized >20
endoscopic accessories
and made it affordable to
poor people
S.Prof. (Dr) Sandeep Nijhawan
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

9. S.Prof (Dr) Shyam Sundar
Sharma
•80 Publications
•Young scientist award Yokohama,
Japan1996
•Young investigator award 1998 Tokyo,
Japan
•National gastroenterology excellence
award 2004
•Two fellowships in advanced
endoscopy and chromoendoscopy
germany
•2 references in “sleisenger and fordtran
textbook of gastroenterology”
•Highest published experience in India in
endoscopic drainage of pancreatic
pseudocyst
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

10. •S.Prof.(Dr) Rupesh Pokharna- 38 Publications
•Prof.(Dr) Bharat Sapra – 10 publications
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

11. Asso. Prof.(Dr) Gaurav Gupta
14 publications
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

12. Asso. Prof. (Dr) Prachis Ashdhir
11 publications
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

13. Asst. Prof. (Dr) Ashok Jhajharia
10 PublicationsCPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

14. Dr Hemendra Bhardwaj
3 publications
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

15. Asst. Prof. (Dr) Surendra Sultania
4 publications
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

16. Asst. Prof. (Dr) Mukesh Jain
2 Publications
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

17. OPD
Daily patient volume – 300-350
Around 1,00,000 patients /year
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

18. GE WARD
•Separate male and female wards
•No of beds – male- 35
female – 25
extra beds- 20
•We have no patient on the floor !!!
•There are > 7500 admissions per year in male ward and
>5000 admissions in female ward
•4 beds for serious patients in Specialty ICU
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

19. GE Ward – Waiting Hall
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

20. GE Ward – Female
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

21. GE Ward – Male
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

22. GE LAB
Reception
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

23. Waiting area
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

24. Corridor
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

25. UGI Endoscopy
40-50 per day
Almost 15000/Yr
Diagnostic
Therapeutic
•EVL/Sclerotherapy
•Glue injection
•Stricture dilatation
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

26. Colonoscopy Room
10-15 per day
Almost 5000/Yr
Diagnostic
Therapeutic
•Polypectomy
•APC
•Sclerotherapy
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

27. ERCP Room
5-10 per day
Almost 3000/Yr
Diagnostic
Therapeutic
•Stone removal
•SEMS placement
•Brush Cytology
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

28. EUS Room
3-5 per day
Almost 1500/Yr
Diagnostic
Therapeutic
•FNAC
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

29. Capsule Endoscopy Room
5-10 per month
Almost 100/Yr
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

30. Enteroscopy room
3-5 per month
Almost 50/Year
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

31. Observation Room
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

32. HOD Chamber
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

33. UNIT I
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

34. UNIT II
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

35. UNIT III
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

36. Lab Incharge Room
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

37. Lab Staff
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

38. Class Room
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

39. Academic Schedule
•Monday – Case presentation
•Tuesday- Management protocol
•Wednesday- Journal club/Guideline
•Thursday- Review article/Seminar
•Friday- Invited Guest lectures/ Conference crux
•Saturday- Radiology/Pathology
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

40. Residents
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

41. Resident Room
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

42. Doctors Station
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

43. Resident Working Area
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

44. Discussion Room
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

45. Ward Staff
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

46. Academic Schedule
•Monday – Case presentation
•Tuesday- Management protocol
•Wednesday- Journal club/Guideline
•Thursday- Review article/Seminar
•Friday- Invited Guest lectures/ Conference crux
•Saturday- Radiology/Pathology
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

47. Residents
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

48. Resident Room
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

49. Doctors Station
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

50. Resident Working Area
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

51. Discussion Room
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

52. Ward Staff
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

53. Nursing Station
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

54. •Each unit has 2 OPD days, 2 endoscopy days and 2
special days
•Special days are reserved for EUS, capsule endoscopy
and enteroscopy
•Referrals are attended by unit on call
•On sundays, referrals are attended by unit on rotation.
•We have 2 residents in the ward round the clock. One 1
st

year and one 2
nd
year
•We try to have the quickest referral services possible !!!
Unit wise Schedule
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

55. FacultyFaculty
GASTRO GASTRO
DepartmentDepartment
PatientsPatients
ResidentsResidents
StaffStaff
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

56. CPC
Case Discussion
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

57. Chief Complaints
•Mrs P, 26/ F
–Vulvar swelling - 6 yrs
–Ulcers in B/L groin area - 5 yrs
–Mucopurulent discharge - 5 yrs
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

58. HOPI
•Vulvar swelling- started in 2010, 3 month of gestation,
gradually progressive ( 1cm 5 cm size)
–Underwent LSCS in July 2010
–Excision done in Jan 2011
–Started growing again and progressed to involve
perineum and buttock
–Slight fluctuation in size with treatment, but never
resolved
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

59. •Ulcers in groin
–Started after excisional surgery
–On sides of swelling and inner side of thigh
–Gradually increased to involve perineum and buttock
( more on Right side)
–Slight pain+, discharge +, no bleeding
•Mucopurulent discharge
–P/V, foul smelling, no blood.
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

60. Relevant History
•H/o multiple episodes of painful redness of both eye
– 2 yrs
–no itching or vision loss
–resolved with eye drops
•No h/o GIT complaints, joint pain, pruritis
•No h/o fever, weight loss, anorexia
•No h/o cough, SOB, hemoptysis
•No h/o any other skin lesion , mucosal lesion, or any
similar swelling in the body.
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

61. Personal history
•Married -7yrs, single female child 6 years old
•No h/o promiscuous behavior
•No h/o STD in husband
•No h/o substance abuse
•No past h/o TB
•No exposure to TB in family
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

62. Treatment history
•Patient received oral antibiotics and steroids from
multiple centers during the course of illness; with
partial improvement in her symptoms.
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

63. Examination
•GPE
–vitals stable
–P-, I-, C-, K-, E-, LNE-
–Cushingoid features+( moon face, hump, stria)
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

64. Discharge- white, purulent over
vagina
Swelling- arising from vulva,
asymmetric, firm lobulated
swelling, extending to
perineum, inguinal and gluteal
region
Ulcers- multiple, genitocrural
fold and gluteal fold, 0.5 to 5
cm, oval to linear deep ulcers,
well demarcated margin( no
induration or heaping),
erythematous base without
much necrotic material
No LNE
Local Examination
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

65. Systemic examination
•CVS- NAD
•R/S-NAD
•P/A-NAD
•CNS- no e/o proximal myopathy
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

66. Case Summary
•26 year old female symptomatic with c/o progressive
swelling of vulva extending up to perineum since 6
years associated with multiple well demarcated
linear deep genitocrural ulcers of varying sizes and
non bloody mucopurulent discharge per vaginum
since 5 years.
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

67. Dermatology Consultation
Dr Vijay Paliwal
Associate Professor
Dr. Banashree Majumdar
Senior Resident
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

68. Clinical History
Young female presented with
asymptomatic vulvar swelling
of seven years duration with
non- healing moderately
painful chronic ulcerations.
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

69. CutaneousExamination
•On examination, left sided
swelling was firm in
consistency and tender
ulcerations were present
linearly along the groin with
oedematous border
associated with multiple
puckered scars. Other
mucosae, skin, hair and
nails normal. Regional LN’s
not enlarged.
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

70. Differential diagnosis:
•Tertiary stage of
Lymphogranuloma venerum
•Hideradenitis suppurativa
polyposa
•Donovanosis (Granuloma
Inguinale)
•Botryomycosis
•Pelvic actinomycosis with
perineal extension
•Malakoplakia
•Tuberculosis Cutis Orificialis
•Pyoderma gangrenosum
•Vulvar Chron’s disease
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

71. Investigations
•Hematology
–CBC- WNL
–ESR- 35 mm/hr (<9)
•Biochemistry
–LFT- WNL
–RFT- WNL
–Ca+/PO4- 8.9/4.2 mg/dl
–FBS- 104 mg/dL
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

72. •ACE levels ( Jan 16) : 17 U/L ( Normal 12-68 U/L )
•Urine Ca+ : WNL
•Microbiology
–Urine R/E-
•25- 30 WBC/HPF, 1-2 RBC( Feb 16)
•2-3 WBC, 1-2 RBC( 17/6/16)
–Urine c/s
•Feb 16- E.coli
•June 16- sterile ( twice)
–Urine AFB x 3- Negative
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

73. •Microbiology
–Cervical discharge
•Gm stain > 30 pmn/HPF
•no fungal element
•wet mount –ve
•Tzank smear- no inclusion bodies, no donovani bodies.
–Cervical swab
•c/s – ureoplasma +ve , mycoplasma –ve
•PCR- C trachomatis +ve, Ureoplasma+ ve
–Tissue fungal c/s- sterile
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

74. •Tuberculin test – 2 x3 mm
•Stool C/S – NAD
•VDRL / HIV/HBs Ag/ anti HCV- Negative
•ASCA/ ANCA- Negative
•CRP- 71.4( <9)
•ECG – NAD
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

75. Imaging
•Chest x ray( 16/6/16) – NAD
•USG abdomen and pelvis (X 4) – NAD
•MRI pelvis( 2/9/15)
–Vulval edema ( L>R), with soft tissue thickening noted
in superficial subcutaneous layer extending up to
perineum
–A sinus tract is also seen extending from right vulval
region to right gluteal region
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

76. Endoscopy
•UGIE( 12/1/16)
–Stomach and duodenum- normal
–Bx taken from both places
•Colonoscopy ( 14/1/16)
–Seen up to 10 cm of ileum- normal
–Colon normal.
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

77. Histology Discussion
Dr. Alpana Jain, Sr. Demonstrator
Moderator-Dr. Sangeeta Sehgal,
Associate Professor.
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

78. •Received a skin punch biopsy on 02/09/2016.
•26 year female
•h/o swelling on vulva since 6 years
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

79. CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

80. CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

81. •Vulval biopsy
•Epithelial hyperplasia
•Subepithelium showing chronic non-specific
inflammatory cells
MGMC Report
2013
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

82. Repeat vulval and
gluteal ulcer biopsy
2013
•Epithelial hyperplasia
•Subepithelium showing giant cell granuloma and dense
chronic inflammatory infiltrate around the keratinous
material
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

83. AIIMS, 2016
•Vulval biopsy
•Epidermis: Follicular plugging
•Subcutis: Epitheloid cell granuloma and chronic
inflammatory cells comprising plasma cells and histiocytes
•AFB and Reticulin: Non- contributory
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

84. Granulomatous lesions of Vulva
Lesion Points in Favour Points Against
Cutaneous TuberculosisCommon cond. In India
Epitheloid cell granuloma
Non caseating , AFB
negative..
Crohn`s disease Age, Site, Non caseating
granuloma .Chronic
gastritis n duodenitis in
G.I.biopsy.P/O Chron’s can
not be ruled out
Negative ASCA level, No
intestinal lesion,
Lymphogranuloma
Venereum (LGV)
Epitheloid cell granuloma,
PCR for C trachomatis +ve
No neutrophils and
necrosis in infiltrate
(stellate abscess),Buboes
absent,
No h/o STD to spouse
Hidradenitis suppurativa Granulomatous lesion with
dense lymphocytic
infiltrate, Follicular
plugging present
No abscess in thelesion
Negative culture of sawb
from lesion for staph.
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

85. s
Lesions Points in favour Points against
Sarcoidosis Epitheloid cell granulomaGiant cells, Schaumann and
Asteroid body absent,
Lympocytes + around
granuloma , Negative ACE
levels and Urine Ca+2,
Absent Reticulin stain,
Normal chest X-ray
Deep Fungal infectionGranulomatous lesion,
discharge +
No growth of fungus on
culture,
Melkersson- Rosenthal
Syndrome
Granulomatous lesionAbsence of triad of facial
paralysis, swelling of face
and lips, deep furrowed
tongue
Idiopathic Granulomaous
Vulvitis
vulvar swelling, granuloma
present
h/o Pain in the swelling,
No h/o frequent relapse
and remissionCPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

86. Lymphogranuloma Venerum
Points in favour
•In tertiary stage strictures
induced lymphatic
obstruction can lead to
enlarged gentalia along
with ulcerations.
•Positive PCR for chlamydia.
Points against
•No history of promiscuity or
of extra marital affair in
either spouse
•No history of preceding
stages or of proctocolitis
•No significant
lymphadenopathy
• No response to T/t
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

87. Hideradenitis suppurativa polyposa
Points in favour
•This variant of Hideradenitis
Suppurativa can present
with polyp like mass lesions
resulting from chronic
lymphedema due to
scarring and stricture
formation at apocrine sites.
Points against
•Sparing of other apocrine
sites
•Absence of interconnecting
sinuses
•Absence of foul smelling
discharge
•No family history
•No seasonal variation
•No disesaes free interval
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

88. Donovanosis
Points in favour
•Initial stage characterised
by beefy ulcer
•where as lymphedema with
esthiomene formation
could be present in
advanced stages.
Points against
•No history of promiscuity or
of extra marital affair in
either spouse
•No pseudo-Bubos
•Non favourable biopsy
findings
•Absence of donovan bodies
in cytoplasm of histiocytes
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

89. Pelvic Actinomycosis with perineal extension
Points in favour
•There are few reports
suggesting A.isarelli leading
to vulvar mass lesions
Points against
•Absence of sulphur granules
•Absence of granulation
tissue with acute and
chronic inflammatory cells
in histology.
•Smear and culture negative.
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

90. Botryomycosis
Points in favour
•May present as
subcutaneous nodules,
abscess, ulcerations.
Points against
•Immunocompetant host
•Absence of history of
trauma
•Absence of discharging
sinuses
•Absence of Splendore-
Hoeppli phenomenon on
histology.
•Negative bacterial culture
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

91. Malakoplakia
Points in favour
•May present as Sub
cutaneous nodules,
ulceration or abscess
formation.
Points against
•Immunocompetant Host
•Mean age of presentation
of this disease is 53 years
•Female sex
•Very low incidence in Asians
•Long duration of disease
•Absence of characteristic
Michellis- Gutman bodies
on histology
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

92. Vulvar Sarcoidosis
Points in favor
•Chronic non healing ulcers
•Chronic Vulvar swelling
•Non-caseating epitheloid
cell granulomas on
histopathology
Points against
•Usually occur with pulmonary
sarcoidosis
•Regress or severty decreases
over course of time
•Normal ACE levels
•Absence of asteroid and
shaumanns bodies
•Presence of lymphocyte
cuffing
•Absence of reticulin fibres
•No response to steroids
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

93. Tuberculosis cutis orificialis
Points in favour
•Chronic ulcerative perineal
lesions
Points against
•Non undermined non
violaceous edges
•Absence of matted lymph
nodes
•Negative mantoux test
•Negative urine culture for
AFB
•Presence of plasma cells
with absence of AFB on
special staining on
histopathology
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

94. Pyoderma gangrenosum
Points in favour
•Spontaneous non healing
painful ulceration with
scarring
•Female sex
Points against
•Usual sites are lower leg
and trunk
•Non tender
•Absence of bluish tinge over
margins
•Absence of bleeding on
touch
•Negative pathergy
•Non characteristic biopsy
findings.
•No response to steroids
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

95. Vulvar Crohn’s disease/Idiopathic vulvar granulomatosis
Points in favour
•Chronic non healing linear
ulcerations with scarring
and esthiomine formation
•Young age presentation
•Fast progression of disease
post vaginal delivery
•Presence of characteristic
non caseating epitheloid
cell granuloma in biopsy
Points against
•Absence of other
cutanoeous findings like
Erythema nodosum,
Pyostomatitis vegetans etc.
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

96. Mechanism of gynaecological involvement in
Chron’s disesae
•Direct extension from diseased bowel
•“Metastatic deposists”- Granulomas or abcesses involving the
perineum, vulva or vagina may form seperately from diseased
intestine or in the absence of active bowel disease.
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

97. Discussion
Dr Gaurav Gupta
Associate Professor
Gastroenterology, SMS Hospital, Jaipur
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

98. Treatment history
Treatment given Response
2010-11( Gynae) Oral and local treatment
Detail NA
No response
2011( surgeon) Excision, antibiotics and
local treatment, ? steroids
Recurred after surgery
along with ulceration and
discharge
2012- 2014( gynae) Ceftriaxone
Metronidazole- oral, local
Doxycycline
Prednisolone for> 1.5 year
Azathioprine > 3 month
~ 20-30 % response only
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

99. 2015( GYNAE, AIIMS) Doxy, metro, Cipro- 2 wk
4 drug nonDOTS ATT- 3 M
No response
2016( Dermat AIIMS) Augmentin- 7 days
Metrogyl- 2 wk
Doxy – 4 wks
Azathioprine
Cyclosporine
~ 20 % improvement ,
mainly discharge
2016 june ( Dermat, MGM
Jaipur
Ceftriaxone- 10 d
Itraconazole- 10 d
Metrogyl- 10d
Prednisolone
ciplox
No significant response
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

100. Differential Diagnosis
•Lymphogranuloma venerum

•Tuberculosis
•Sarcoidosis
•Crohn’s disease
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

101. Differential diagnosis
•Tuberculosis
–Favour- common disease, age , presentation,
granuloma
–Against- no h/o exposure, no past or present source,
AFB, PCR –VE, Tuberculin test- 2X 3 mm, no response
to ATT trial
•Sarcoidosis
–Usually no ulcer or sinus
–ACE, Ca+, urine Ca+, CXR- normal
–HPE not supportive
–No significant response to steroids
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

102. •LGV- tertiary stage
–Favour-
•Age
•Granulomatous ds
• PCR+
–Against-
•Partner asymptomatic
•No LNE( buboes)
•Usually ulcers heals spontaneously within 2-3 wks, in
later stages only lymphoedema / canalicular
obstruction persist
•No anorectal symptoms
• PCR may be positive in 4-5% general population
•No significant response to antibiotics
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

103. •Crohn’s disease
–Favour-
•Age
•Noncaseating granuloma
•Linear sharp ulcers
•Episcleritis
•Gastroduodenal chronic inflammation
–Against-
•No other mucocutaneous lesions
•No GIT symptoms
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

104. •Final Diagnosis
–Metastatic Vulval CD – Mixed variety with perineal
extension
•Resolved episcleritis
•Refractory to standard treatment
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

105. Management
–In view of previous nonresponse
–Planned for biological therapy
–Inj adalimumab 160 mg( 8/8/16)- 80
mg(22/8/16)- 40 mg (6/9/16) s/c along with
azathioprine 50 mg bid
–Symptomatically better ~ 70% ( patient
assessment)
–No discharge, ulcer started healing and depth
decreased
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

106. After 2 cycles of Adalimumab
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

107. •Extraintestinal manifestation of CD- ~35%
–Ocular
–Musculoskeltal
–Mucocutaneous – 22- 44%
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

108. CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

109. CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

110. Metastatic Crohn’s Disease(MCD)
•Defined by Mountain et al in 1970
•Cutaneous lesions of CD that are discontinuous from
GIT
•~ 20% cases may precede GI CD, (usually 2 months to 4
years, reported up to 16 years)
•1/3
rd
have active GIT disease
•Predilection for moist area
•Pathogenesis
–Unknown
–Circulating antigen – type I hypersensitivity
–Autoimmune cross reactivity
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

111. CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

112. Vulval CD
•~ 130 Cases reported in the literature
•Approx. 80% along with intestinal CD & 48% have
perianal disease
•91% of vulval CD metastatic CD; 9% direct extension
•Appox.25% precede GIT disease
•Mean age of presentation :34 years
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

113. Types of vulval CD
Vulval swelling and edema- 67%
Ulcers- knife like characterstic-40%,
more in MCD
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

114. Types of vulval CD
Hyperplastic lesion-24%
Chronic suppuration-17%
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

115. •Symptoms-
–Swelling, ulcer, pain, pruritus, erythema, discharge
•Association-
–Oral ulcers, eye lesions, arthitis
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

116. Treatment
•No guidelines
•Topical- steroids ( only super potent), tacrolimus
•Systemic
–Antibiotics
–Steroids
–Azathioprine, cyclosporine, MMF
–Biologicals- infliximab, adalimumab
•Surgery
• Medical refractory cases, I/D of abscess, and aesthetic
purpose
•I/D, Local excision, partial and complete vulvectomy
•Supplemental Rx- hyperbaric O2 therapy
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

117. CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

118. Biological therapy in vulval CD
•As in GIT CD, anti TNF α agents found to be effective
in vulval CD
– Infliximab
–16/25 remission, 1 acute rxn, 4 nonresponder
•Adalimumab
–5/7 patients responded
–More efficacious
–Easy to Administer, Less side effects
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

119. CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

120. Biological in CD
Crohn’s disease with Rectovaginal fistula
•35 yr F, Bloody diarrhea for 2 year
•Granulomatous colitis (2014) - 2014 ATT with mesalamine for
9 month- some relief
•Treated as Crohn’s- mesalamine and low dose steroid - partial
relief +
•Fistula Ano in Dec 2015 – surgery done
•Jan 16 – foul smelling feculent discharge P/V, Imaging s/o
Rectovaginal fistula, sigmoidoscopy confirmed it with severe
colitis
•Started on Injection Adalimumab (27/4/16) along with
azathioprine- total 10 doses given
•Improvement after 2
nd
dose, at 8 wk colonoscopy- normal
colonic mucosa with no fistula
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

121. Stricturing crohn’s disease
•45 M, colonic CD for 2 years, was on mesalamine and
azathioprine – in remission
•Presented with increased stool frequency with pain
abdomen for 2 months
•Sigmoidoscopy – ulcerated strictured segment in
descending colon, scope not negotiable
•Started on Adalimumab , azathioprine,- after 4 cycles –
patient asymptomatic, mucosa normal, stricture seen but
scope negotiable easily
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

122. Points of discussion…….
•Duration of therapy
–Till the ulcers resolve?
•Role of maintenance therapy as in intestinal CD?
•Whether there is Requirement of surgery?
•How to Follow up for GIT involvement?
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

123. TAKE HOME MESSAGE…..
•Vulval CD patients’ symptoms are gynecological in nature
and patients would probably present first in this
speciality . Therefore a great awareness of this disease
entity is required.
•Early diagnosis and prompt treatment can help to
prevent complicated course of disease
•Definitive diagnosis can only be achieved by biopsy.
•Once diagnosis is made, management requires a multi-
team approach with gastroenterologist, dermatologist or
surgeon.
CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator

124. CPC Team and Dr. Monica Jain Coordinator,
Dr. Lokendra Sharma Co cordinator