PRIMARY NONSPECIFIC ULCERATION OF THE SMALL BOWEL

A case report of delayed lower intestinal bleeding after organophosphate poisoning

Background

Organophosphate poisoning is a serious issue and it results in significant casualties in developing countries. Since agriculture remains an important and necessary sector of human society and organophosphate are commonly used in agriculture, it is difficult to prevent organophosphate poisoning. Gastrointestinal bleeding is not a common but life threatening symptom of organophosphate poisoning. We report a rare case of gastrointestine bleeding due to organophosphate poisoning.

Case presentation

A 78-year-old woman presented to our hospital approximately 12 h after ingesting a mouthful of organophosphate and benzodiazepines in a suicide attempt. Six weeks after successful medical treatment for respiratory failure, she developed recurring melena. Colonoscopy and esophagogastroduodenoscopy findings were negative for ulcers or bleeding. Enteroscopy revealed severe circumferential ulcers with luminal narrowing 10 cm proximal to the ileocecal valve. The patient underwent a 100-cm ileum resection after failed medical treatment and recovered uneventfully. The resected terminal ileum demonstrated severe inflammation and a sharp transitional zone between the healthy and injured mucosa approximately 50 cm proximal to the ileocecal valve. Pathological examination revealed an injured mucosa with inflammatory cell infiltration and structural damage. This case highlights a rare event of OP poisoning with late-onset lower gastrointestinal bleeding, which prolonged the patient’s recovery course and parenteral alimentation period.

Conclusion

We report a rare case of a patient with organophosphate poisoning, with late-onset lower GI tract bleeding, which raised clinical awareness regarding the organophosphate poisoning that induce intestinal symptoms.

Cryptogenic multifocal ulcerous stenosing enteritis (CMUSE): a 20-year single-center clinical and radiologic experience

OBJECTIVE

The purpose of this article is to describe clinical and imaging characteristics of confirmed cases of cryptogenic multifocal ulcerous stenosing enteritis (CMUSE).

METHODS

Retrospective review of electronic medical records identified patients considered for a diagnosis CMUSE over 20-years in a single large tertiary center. Clinical data were abstracted and diagnosis was confirmed based on published criteria. Two GI radiologists reviewed CT and MR enterography (CTE/MRE) exams in consensus of confirmed patients to characterize the imaging features of CMUSE.

RESULTS

Eight patients with confirmed CMUSE diagnosis were included for image review, and 9 CTEs and 1 MRE were analyzed. Most patients were males (75%) with a median age at diagnosis of 59.5 years (25-71) presenting with iron deficiency anemia (75%). Patients were commonly refractory (87.5%) to their first therapy, including steroids, with half being refractory to surgical intervention. Major imaging features included multiple (≥ 5; 88%; 7/8), short (< 2 cm; 100%; 8/8), circumferential (100%; 8/8) strictures with moderate wall thickening (6-9 cm), and stratified hyper enhancement (100%; 8/8) located in the ileum (100%; 8/8). Median proximal small bowel dilation was 2.95 cm (2.5-4.1 cm). No CMUSE cases demonstrated penetrating disease (e.g., abscess, fistula).

CONCLUSION

CT and MR enterography are invaluable tools in the multidisciplinary diagnostic evaluation of CMUSE, a rare cause of small bowel strictures with overlapping clinical and imaging features of Crohn's disease and NSAID enteropathy.

Long-term follow-up of nonspecific small bowel ulcers with a benign course and no requirement for surgery: is this a distinct group?

Background

Nonspecific small bowel ulcers are rare and surgical intervention is often believed to be elective. Since the extensive investigation of the small bowel in the 1990s, there have been limited reports of these ulcers and the updates have been unsatisfactory. The aim of this study was to explore the clinical features and natural histories of nonspecific small bowel ulcers through prospective observational study.

Methods

We reviewed the medical records of all patients who had undergone ileocolonoscopy or enteroscopy between 2000 and 2005 in a tertiary referral hospital. Seven patients with small bowel ulcers of unknown cause were identified. These patients were prospectively followed in a prolonged observation until March 2010.

Results

All seven patients (mean age: 54.7 years) presented with mild gastrointestinal symptoms, including chronic diarrhea and/or abdominal pain/discomfort, except for one who was asymptomatic when surveyed for colon polyps. Most patients were suspected of having functional bowel disorders for a long time (4.4 years) before small bowel ulcers were demonstrated on ileoscopy. The ulcers were characteristically multiple, superficial, and small (3-6 mm), locating at the terminal ileum and/or ileocecal valve. Various empirical treatments were applied, and most patients felt partly improved, even relieved. However the gastrointestinal symptoms did not always correlate with the presence of ulcers, and the ulcers tended to be either persistent (4 patients) or recurrent (1 patient). Ileocolonoscopy was repeated 4.1 times during follow-up, even after the lesions had healed. The characteristics of the ulcers, if still present during follow-up, were similar to their earlier characteristics. No patient experienced exacerbation or complications, such as intestinal obstruction, perforation, or bleeding. All patient survived and no surgical intervention was involved during the prolonged follow-up (7.0 years).

Conclusion

The reported patients with nonspecific small bowel ulcers experienced benign courses, inconsistent with previous reports. Without extensive investigation, this disease can be confused with functional bowel disorders.

Jejunal perforation possibly induced by slow-release potassium in a patient with Crohn's disease

A case of small bowel ulceration and perforation possibly due to therapy with Klotrix in a patient with Crohn's disease is presented. Following emergent surgery with creation of a diverting loop jejunostomy, subsequent reestablishment of intestinal continuity was carried out with excellent clinical results. Gastrointestinal mucosal lesions possibly due to wax-matrix potassium chloride preparations are reviewed.

Nonspecific small bowel ulceration

Six patients (4 male, 2 female) developed nonspecific small bowel ulceration between the ages of 4 months and 76 y. Five had gastrointestinal haemorrhage, usually chronic and resulting in iron deficiency anaemia. Four had features of subacute intestinal obstruction; there were no perforations. A small bowel enema was the most useful single investigation for delineating the lesions, and surgical excision was curative in all but one case. No aetiological causes could be implicated, other than in one patient taking a daily tablet of Navidrex-K.

Solitary nonspecific ileal ulcer. Diagnosis by coloileoscopy in a patient with previously assumed irritable bowel syndrome

We present a case of solitary nonspecific ileal ulcer found by coloileoscopy in a patient with previously assumed irritable bowel syndrome. Follow-up endoscopies two weeks after initiation of short-term prednisone therapy, and again four months later, demonstrated rapid and persistent healing. This observation raises the question of whether or not primary ileal ulcers are indeed as rare as previously assumed when only surgical and autopsy findings were taken into consideration. Also, the natural history of this clinical entity, in general, could be somewhat more benign than suggested by those ulcers in which complications make surgery necessary, since these cases may not adequately reflect the full clinical spectrum of nonspecific small-bowel ulcers.

Clinicopathologic study of nonspecific ulcers of the small intestine

Fifty-nine cases (31 men and 28 women) of nonspecific small bowel ulceration, representing the Mayo Clinic experience from 1956 to 1979, are reviewed. The average age was 51 years. Presenting symptoms or signs were those of intermittent small bowel obstruction (63%), blood loss (25%), and acute abdomen (12%). Whereas 78% of the ulcers were located in the ileum, 15% in the jejunum, and 7% in the jejunoileum, perforation was by far more common in the jejunum (78%) as compared with the ileum (11%). Diagnosis was rarely made preoperatively, although abnormalities were noted roentgenographically in 66%. Treatment was surgical and was usually curative. Operative mortality was 8.5%. No single cause was implicated.

Idiopathic and drug-induced ulceration of the small intestine

Ulceration of the small intestine is an uncommon lesion of multifactorial origin. The most important factor responsible for the reported increased incidence is the ingestion of enteric-coated potassium chloride. It is desirable that potassium supplements be given in another form, for example as a slow-release preparation. Other drugs which may play a part in the aetiology include corticosteroids and phenylbutazone.

Diagnosis is difficult and ulceration is usually only demonstrated after one of the complications (obstruction, perforation, or haemorrhage) has occurred. It is imperative that a full drug-taking history is obtained.

Laboratory tests are not helpful in diagnosis, but where radiological studies are carried out they often contribute useful information.

If the symptoms of such an ulcer are severe enough to warrant laparotomy, then the treatment of choice is excision of the affected segment followed by end-to-end anastomosis.

Primary non-specific ulcer of ileum presenting with massive rectal haemorrhage

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Small bowel ulceration associated with thiazide and potassium therapy: review of 13 cases

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