Cryptogenic multifocal ulcerous stenosing enteritis: a review of the literature

MR enterography in Crohns disease and beyond: a pictorial review : Beyond Crohn's: a pictorial guide to MR enterography in small bowel disease

Magnetic resonance enterography (MRE) has become an essential imaging modality for evaluating small bowel disorders, particularly Crohn's disease (CD), due to its superior soft-tissue contrast, multiplanar capabilities, and lack of ionizing radiation. While radiologists are generally familiar with the MRE findings of CD, several other small bowel entities can present with similar imaging features, potentially leading to diagnostic challenges. This pictorial review comprehensively illustrates the MRE findings of CD and its various mimickers, including Ulcerative colitis (UC), intestinal tuberculosis (ITB), Non-steroidal anti-inflammatory drug (NSAID) induced enteropathy, cryptogenic multifocal ulcerating and stenosing enteropathy (CMUSE), celiac disease, gastrointestinal endometriosis, intestinal lipomatosis, lymphangiectasia, eosinophilic enteritis, encapsulating peritoneal sclerosis, adhesions, radiation enteropathy, and intestinal angioedema etc. We discuss the key imaging features that can help a radiologist differentiate these conditions, highlight specific MRE sequences useful for diagnosis, and provide clinically relevant context for each entity. This review serves as a practical guide for radiologists and clinicians in recognizing and distinguishing various small bowel pathologies that may simulate CD on MRE, ultimately aiding in appropriate patient management.

A Case Report: Cryptogenic Multifocal Ulcerative Stenosing Enteritis - A Diagnostic Challenge Mimicking Crohn's Disease

Introduction

Cryptogenic multifocal ulcerative stenosing enteritis (CMUSE) is a rare and underrecognized small bowel disorder that often mimics Crohn's disease, leading to delays in diagnosis and misdirected treatment. Given its relapsing nature and resistance to conventional inflammatory bowel disease (IBD) therapies, CMUSE presents significant diagnostic and therapeutic challenges.

Case Presentation

We present the case of a 41-year-old male with chronic anemia, fatigue, weight loss, and intermittent abdominal pain with melena, who remained undiagnosed for 9 years despite extensive evaluations. Imaging and endoscopy failed to identify a definitive cause, and management with TNF inhibitors and IL-12/IL-23 blockade provided only temporary relief. The patient required multiple surgical resections due to recurrent strictures. Pathological examination consistently revealed multifocal jejunal ulceration with stenosis but lacked granulomas, vasculitis, or systemic inflammatory markers, ultimately confirming CMUSE. Given its distinct pathology and treatment resistance, differentiating CMUSE from Crohn's disease is essential. The patient's ongoing management includes upadacitinib, a JAK1 inhibitor, which may help modulate immune pathways contributing to ulcer formation and stricture development.

Conclusion

This case underscores the need for heightened clinical recognition of CMUSE, particularly in patients with unexplained small bowel strictures and ulceration unresponsive to standard IBD therapies. Genetic testing may aid in distinguishing CMUSE from Crohn's disease, preventing unnecessary immunosuppressive treatments. Further research is necessary to establish effective, targeted therapies and improve outcomes for patients with this rare condition.

Discrimination of pediatric cryptogenic multifocal ulcerous stenosing enteritis from small bowel Crohn's disease and gastrointestinal tuberculosis: A retrospective study (with videos)

INTRODUCTION

Cryptogenic multifocal ulcerous stenosing enteritis (CMUSE) is a rare entity that mimics various inflammatory strictures of the small intestine. Pediatric literature is scarce. We analyzed the clinical, radiological, endoscopic and histopathological features of children with CMUSE that differentiate it from small bowel Crohn's disease (SBCD) and gastrointestinal tuberculosis (GITB).

METHODS

CMUSE was diagnosed by the following criteria: (1) unexplained small bowel strictures with superficial ulcers, (2) chronic/relapsing ulcers of small bowel after resection, (3) no signs of systemic inflammation, (4) absence of other known etiologies of small bowel ulcers. SBCD and GITB were diagnosed based on standard criteria. The clinical features, laboratory parameters, radioimaging, endoscopy (including video capsule endoscopy [VCE], intra-operative endoscopy), histopathological features and treatment outcome were noted.

RESULTS

Out of 48, CMUSE was diagnosed in 13 (27%) isolated small bowel and ileocecal strictures, while GITB and SBCD accounted for 41% and 21% cases, respectively. Common presentations were sub-acute obstruction (46%), obscure gastrointestinal bleeding (38%) and protein-losing enteropathy (38%). CMUSE patients had significantly longer disease duration compared to SBCD and GITB (p < 0.001). SBCD (90.0%) and GITB (85%) cases had elevated C-reactive protein (CRP), none with CMUSE had elevated CRP (p < 0.001). The disease was localized in jejunum (100%) and proximal ileum (56%) in CMUSE, ileocecal region (85%) in GITB, but evenly distributed in small intestine in SBCD. Endoscopy showed evenly placed, superficial, circumferential ulcers with strictures in CMUSE, deep linear ulcers in SBCD and circumferential ulcers in GITB. Upfront immunosuppression was given in four; three (75%) of them relapsed. Only surgery was done in three with one (25%) having relapse. Upfront surgery followed by immunosuppression was used in six, but all relapsed and two required repeat surgery.

CONCLUSION

CMUSE is important but underdiagnosed in children. Lack of constitutional symptoms, normal inflammatory parameters and characteristic ulcers with strictures helped in differentiating CMUSE from GITB and SBCD.

Cryptogenic Multifocal Ulcerating Stenosing Enteropathy: A Rare Case of Small Bowel Stenosis

BACKGROUND Cryptogenic multifocal ulcerating stenosing enteropathy (CMUSE) is a rare noninfectious chronic inflammatory disease of the digestive tract confined to the small bowel. Chronic inflammatory wasting leads to protein loss and weight reduction, and some patients eventually develop small bowel stenosis. The etiopathogenesis of CMUSE remains unknown. CASE REPORT A thin 62-year-old man was admitted to the hospital with abdominal pain and distension accompanied by bilateral lower-extremity edema for 2 months. After a series of medical tests, rheumatic or immune-related diseases, hyperthyroidism, and tuberculosis were excluded, and common digestive system diseases were also excluded. Abdominal CT showed incomplete obstruction of the small bowel. Enteroscopy showed small-bowel luminal narrowing. The patient subsequently underwent partial resection of the small bowel with end-to-side anastomosis. The small-bowel stricture was about 120 cm from the ileocecal junction, and about 12 cm of small bowel was resected. Postoperative pathology of the resected material revealed multifocal ulceration of the mucosa with massive inflammatory cell infiltration and extensive hyperplastic fibrous tissue, consistent with the characteristics of CMUSE disease. At follow-up 6 months after surgery, he had no abdominal pain or distension, and his anemia and lower-extremity edema were improved. CONCLUSIONS CMUSE diagnosis requires a combination of patient history, imaging, endoscopy, pathology, and exclusion of other digestive disorders, such as Crohn's disease. It is a chronic wasting disease, often accompanied by weight loss, abdominal pain, melena, and hypoproteinemia. Surgery is an important treatment for intestinal strictures caused by CMUSE.

What is the appropriate treatment strategy for cryptogenic multifocal ulcerative stenosing enteritis? A single-center experience from China

Background

There are few reports on standard treatment and long-term prognosis in patients with cryptogenic multifocal ulcerative stenosing enteritis (CMUSE), particularly in patients in whom remission could not be induced by steroids. The aim of this study was to evaluate the treatment response and progression-free periods of patients with CMUSE and to identify the factors predictive of steroid resistance.

Methods

This was a retrospective cohort study that included 25 patients with clinically confirmed CMUSE between 1984 and 2021 from the enteropathy clinic of a tertiary care center. For statistical analyses, chi-square test or Fisher’s exact test were used for categorical variables. Survival curves were plotted using the Kaplan–Meier method.

Results

The overall median progression-free period was 48 months (range, 1–108 months) after comprehensive therapy, and initial manifestation with severe bleeding rather than ileus was associated with the long-term efficacy. Patients with steroid resistance (N = 10, 55.6%) had poor prognosis, and non-responders had more favorable baseline clinical characteristics, with a higher percentage of female patients (60% vs. 12.5%), earlier disease onset (26.5 years vs. 39 years), rapid progression (42 vs. 108 months), severe anemia (80% vs. 50%), and hypoalbuminemia (50% vs. 0%), in accord with lymphangiectasia or angioectasia identified in pathology.

Conclusion

There is no guaranteed treatment strategy in the maintenance of long-term clinical remission for CMUSE patients, particularly in whom with steroid resistance. Female patients with early symptoms onset, severe gastrointestinal hemorrhage and hypoalbuminemia seem to have poor long-term prognosis.

Capsule retention caused by cryptogenic multifocal ulcerous stenosing enteritis

INTRODUCTION

cryptogenic multifocal ulcerous stenosing enteritis (CMUSE) is a rare illness. Capsule retention (CR) has been reported in a few cases of CMUSE.

METHODS

we present four cases of CMUSE with CR. None of the patients showed any symptoms or signs of small bowel obstruction before capsule endoscopy (CE). All patients denied a history of non-steroidal anti-inflammatory drugs intake, radiotherapy treatment or abdominal surgery.

RESULTS

CE disclosed circumferential stenosis with or without ulcers in the small bowel, some accompanied by mucosal edema, white spots and nodules. All patients underwent an elective surgery to remove the retained capsule and resect the lesions.

CONCLUSION

CE plays a positive role in diagnosing CMUSE. CE findings are as important as CR to alert about the diagnosis of CMUSE.

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.

A case report of intestinal obstruction caused by cryptogenic multifocal ulcerous stenosing enteritis

Background

Cryptogenic multifocal ulcer stenosing enteritis (CMUSE) is a rare disease characterized by multiple superficial ulcers, stenosis, and obstruction of the small intestine of unknown origin, and the course can recur.

Case presentation

We encountered a 62-year-old male patient with intestinal obstruction. The patient was admitted to the hospital for surgical treatment due to intestinal obstruction, and was diagnosed with cryptogenic multifocal ulcer stenosis enteritis due to comprehensive surgery and postoperative pathological considerations.

Conclusion

In the future, we will continue to follow up the patient. The present study aims to remind clinicians of this disease, and reduce the incidence of misdiagnosis.

Retrospective study of the differential diagnosis between cryptogenic multifocal ulcerous stenosing enteritis and small bowel Crohn's disease

BACKGROUND

Being a rare disease, cryptogenic multifocal ulcerous stenosing enteritis (CMUSE) is easily misdiagnosed as small bowel Crohn's disease (SBCD).

AIMS

This study was aimed to compare clinical features of CMUSE to SBCD.

METHODS

Fourteen patients with CMUSE and 61 patients with SBCD were retrospectively analyzed.

RESULTS

Hematochezia was more frequent in CMUSE patients (10, 71.4% vs 23, 37.7%, P = 0.022), while diarrhea was more common in SBCD patients (23, 37.7% vs 0, 0.0%, P = 0.015). More patients with CMUSE developed intestinal stenosis than with SBCD (14, 100% vs 37, 60.7%, P = 0.011). 30 (50.0%) SBCD patients and none CMUSE patients had an elevated erythrocyte sedimentation rate level (P = 0.001). Extra-enteric findings found by computed tomography enterography were significantly more prevalent in SBCD patients than in CMUSE patients (25,71.4% vs 3,25%, P = 0.013). Longitudinal ulcers found by endoscopy were more common in SBCD patients (16, 37.2% vs 0, 0.0%, P = 0.041), while circumferential ulcers were more common in CMUSE patients (6, 54.6% vs 8, 18.6%, P = 0.041). All ulcers observed in CMUSE patients were within mucosal and submucosal layers, but 8 (44.4%) SBCD patients had deep ulcers that reached beyond submucosal layers (P = 0.003). Ulcers were located at strictures in 9 (90.0%) CMUSE patients but only in 1 (5.6%) SBCD patient (P = 0.000).

CONCLUSIONS

Gastrointestinal symptoms, erythrocyte sedimentation rate levels, radiologic, endoscopic and pathologic features help to distinguish CMUSE from SBCD.

Case report of cryptogenic multifocal ulcerous stenosing enteritis (CMUSE): a rare disease may contribute to endoscopy-capsule retention in the small intestine

Background

CMUSE is a rare disease whose diagnosis remains difficult because the lesion is confined to the small bowel.

Case presentation

Here, we present a case of 43-year-old female patient suffered chronic abdominal pain for 20 years, and finally diagnosed with CMUSE. Capsule endoscopy was performed when general endoscopic investigation failed to find the lesion, but the capsule was stranded in the small intestine. Moreover, capsule retention results in acute intestinal obstruction. Thus, surgery was performed and CMUSE was confirmed. The patient was recovered after partial small intestine resection.

Conclusions

Capsule retention occurred in nearly 60% of patients with CMUSE. Capsule endoscopy should be avoided when the patient is suspected of CMUSE, especially with severe anemia and radiologic finding in the ileum.

A rare cause of multiple small bowel ulcers and strictures in a 10-year-old child

Enteritis and small bowel ulcers can be caused by inflammatory bowel disease, drug-induced enteritis, cytomegalovirus, tuberculosis, or intestinal lymphoma. Cryptogenic multifocal ulcerous stenosing enteritis (CMUSE) is an uncommon idiopathic cause of ulceration and stricture of the small bowel. CMUSE can occur in adults, but only few pediatric cases have been reported. Inflammatory bowel disease and other causes should be carefully sought first before the diagnosis of CMUSE can be made. Previous reports demonstrated that surgical intervention may be necessary for both diagnostic and therapeutic purposes. With regard to the management, systemic corticosteroids may help, and surgery plays a role in patients present with signs of intestinal obstruction. We report a young girl who presented with a prolonged history of refractory iron deficiency anemia with protein-losing enteropathy without other obvious gastrointestinal symptoms. She underwent several laboratory and endoscopic investigations as well as histopathology of the resected full-thickness small bowel area before a proposed diagnosis of CMUSE was made. A trial of immunosuppression (both prednisolone and azathioprine) was initiated that provided a relatively satisfactory result.

Roles of Organic Anion Transporting Polypeptide 2A1 (OATP2A1/SLCO2A1) in Regulating the Pathophysiological Actions of Prostaglandins

Solute carrier organic anion transporter family member 2A1 (OATP2A1, encoded by the SLCO2A1 gene), which was initially identified as prostaglandin transporter (PGT), is expressed ubiquitously in tissues and mediates the distribution of prostanoids, such as PGE₂, PGF_2α, PGD₂ and TxB₂. It is well known to play a key role in the metabolic clearance of prostaglandins, which are taken up into the cell by OATP2A1 and then oxidatively inactivated by 15-ketoprostaglandin dehydrogenase (encoded by HPGD); indeed, OATP2A1-mediated uptake is the rate-limiting step of PGE₂ catabolism. Consequently, since OATP2A1 activity is required for termination of prostaglandin signaling via prostanoid receptors, its inhibition can enhance such signaling. On the other hand, OATP2A1 can also function as an organic anion exchanger, mediating efflux of prostaglandins in exchange for import of anions such as lactate, and in this context, it plays a role in the release of newly synthesized prostaglandins from cells. These different functions likely operate in different compartments within the cell. OATP2A1 is reported to function at cytoplasmic vesicle/organelle membranes. As a regulator of the levels of physiologically active prostaglandins, OATP2A1 is implicated in diverse physiological and pathophysiological processes in many organs. Recently, whole exome analysis has revealed that recessive mutations in SLCO2A1 cause refractory diseases in humans, including primary hypertrophic osteoarthropathy (PHO) and chronic non-specific ulcers in small intestine (CNSU). Here, we review and summarize recent information on the molecular functions of OATP2A1 and on its physiological and pathological significance.

Case report of a pair of siblings with cryptogenic multifocal ulcerating stenosing enteritis: A rare disease easily to be misdiagnosed as Crohn disease

RATIONALE

The rare disease cryptogenic multifocal ulcerous stenosing enteritis (CMUSE) is characterized by multiple and recurring small intestinal ulcers with stenosis of unknown causes. In clinic, it is difficult to be differentiated from the inflammatory bowel disease, especially the Crohn disease.

PATIENT CONCERNS

Here we report a pair of siblings who suffered from long-time anemia and abdominal pain and misdiagnosed with inflammatory bowel disease (IBD) for many years.

DIAGNOSES

They were finally diagnosed with CMUSE with intestinal obstruction.

INTERVENTIONS AND OUTCOMES

They both accepted surgical treatment and recovered well. No abdominal symptom appeared in the two-year follow-up.

LESSONS

This report underscores that CMUSE patients may have a long course of suffering from anemia and abdominal pain, normal inflammatory markers and normal colon, and sometimes have a family history of CMUSE. Surgery of segmental bowel resection is a good way to solve intractable intestinal obstruction in CMUSE.

Cryptogenic Multifocal Ulcerous Stenosing Enteritis (CMUSE): A Tale of Three Decades

We present a patient who, over the course of 35 years, presented with repeated episodes of ileus and melena and was misdiagnosed several times, leading to several surgeries. Macroscopic and microscopic features of his resected intestine were compatible with cryptogenic multifocal ulcerous stenosis enteritis (CMUSE), but additional angioectatic lesions were also noted. The patient responded dramatically to hormonal therapy consisting of ethinylestradiol and norethisterone. To our knowledge, this is the first reported case of CMUSE that has shown response to hormonal therapy. We suggest that this is a variant of CMUSE in which vasculopathy plays a role in the pathogenesis.

Clinicopathologic features of chronic nonspecific multiple ulcers of the small intestine

Chronic nonspecific multiple ulcers of the small intestine is a rare but distinct clinical condition, characterized by multiple small intestinal ulcers of nonspecific histology and chronic, persistent gastrointestinal bleeding without nonsteroidal anti-inflammatory drug use. However, because of the term "nonspecific" in its nomenclature, some gastroenterologists have misinterpreted the disease as the condition with small intestinal ulcers caused by undetermined etiologies without considering clinical features. Such misinterpretation has led to the heterogeneity of clinicopathologic features of the disease, as well as to ambiguity regarding a possible genetic contribution. It thus seems necessary to recognize the clinical entity of the disease precisely to avoid misinterpretation. In this review, we describe the clinicopathologic features, differential diagnosis, and the possibility of a genetic contribution to the disease.