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

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.

Endoscopy of the terminal ileum. Diagnostic yield in 400 consecutive examinations

A prospective study was undertaken to investigate the feasibility and diagnostic yield of ileoscopy as an extension of total colonoscopy. The distal 15 to 40 cm of the terminal ileum were visualized in 400 of 555 consecutive patients submitted to total colonoscopy (72 percent). Intubation of the terminal ileum was not successful in 42 patients (8 percent), not tried in 63 (11 percent), and hampered by inadequate colonic cleansing in 50 (9 percent). We observed 13 patients with terminal ileitis and seven rare findings such as nonspecific ileal ulcer or non-Meckelian diverticulum, etc., adding to a total of 20 pathologic findings in 400 examinations (5 percent). In a further group of 98 patients, useful diagnostic information was gained by the demonstration of normal ileal findings, making ileoscopy clinically valuable in 118 of 400 examinations (29.5 percent) in this series. We suggest routine endoscopy of the terminal ileum in all patients with suspected or established inflammatory bowel disease and/or persistent diarrhea, lower gastrointestinal tract bleeding, or irritable bowel syndrome, in whom the diagnostic procedure includes colonoscopy. In patients with colorectal tumors or polyps, the diagnostic yield will be unrewarding.