Radiology in Idiopathic chronic ulcerative enteritis

Fatal course of idiopathic chronic ulcerative enteritis with panenteritis and perforation: a case report and review of literature

BACKGROUND

Idiopathic chronic ulcerative enteritis (ICUE) is a very rare disease with high mortality. Because of clinical rarity, several small case reports have been published and there is a lack of large sample study. Preoperative definite diagnosis is difficult. Although definite treatment for ICUE is radical surgical resection, surgical decision in operative field is difficult.

CASE PRESENTATION

A 77-year-old man came to the emergency department with complaints of a 1-day history of abdominal pain and abdominal distension. Abdominal computed tomography revealed ileus and focal free air. Laparotomy revealed multiple small bowel tiny perforations in the ileum. The serosa surface in the whole small bowel had small multiple yellowish tiny discolored lesions. Despite the presence of multiple mucosal ulcers in entire small bowel, the ileum including perforation site was resected segmentally. Microscopically, mucosal ulcers in resected small bowel demonstrated transmural inflammation, no granuloma, and no lymphoid aggregates. These features were consistent with a diagnosis of ICUE with panenteritis and perforation. After surgery, the patient's general condition gradually aggravated. Unfortunately, the patient died of multiple organ failure on post-operative day 14.

CONCLUSION

Surgically, the decision including resection range, anastomosis or enterotomy becomes difficult in ICUE with panenteritis. According to recent 40 year's revised data, the post-operative mortality of ICUE is about 53.4%. Although ICUE is rare, its recognition is important for appropriate diagnosis and treatment. Retrospective multicenter case studies are required to determine proper treatment and improve prognosis.

Small Bowel Ulcers

Treatment of small intestinal ulcers depends on the cause of the ulcers. Ulcerations of the small intestine (apart from duodenal ulcers) are uncommon. Two diverse syndromes of idiopathic small bowel ulcerations include the isolated nonspecific ulcer and idiopathic chronic ulcerative enteritis (ICUE). Treatment of isolated nonspecific ulcers include discontinuation of medications known to cause nonspecific ulcerations, balloon dilation of strictures, and segmental resection of involved segments. Treatment of ICUE includes a diet trial of gluten restriction and consideration of early surgery because of the potential for associated malignancies. Steroid therapy has not been shown to be effective in the treatment of ICUE.

Malignant histiocytosis and ulcerative jejunitis of the small intestine

Thirteen patients are described with malignant histiocytosis of the small bowel, five of these also having ulcerative jejunitis. In seven patients the malignancy arose as a complication of established coeliac disease. In six patients there was a much shorter history, but these patients also had coeliac disease. The prognosis is poor and there is a need to establish the diagnosis early, in the hope that chemotherapy may be helpful. The diagnosis should be suspected radiologically where there are areas of luminal narrowing associated with nodular thickening of the valvulae, alternating with more dilated portions of the small intestine with normal valvulae.