Sequential stenotic strictures of the small bowel leading to obstruction

Small bowel obstruction secondary to phytobezoar in a patient with myotonic dystrophy

A male patient in his 30s, with myotonic dystrophy (DM), presented to the emergency department with abdominal pain and vomiting. CT imaging revealed a soft tissue lesion in the terminal ileum causing small bowel obstruction (SBO). The patient underwent diagnostic laparoscopy which allowed identification and removal of the obstructing lesion. This was in the form of an intact, undigested potato, a phytobezoar. Bezoars are collections of undigested material found in the gastrointestinal (GI) tract, a phytobezoar is composed of plant material and is the most common form of bezoar. DM is a multisystem disorder characterised by skeletal muscle weakness, however it often presents with GI symptoms and the muscles of mastication are often affected. DM is a known risk factor for bezoar formation and should be considered as an important differential in DM patients presenting with SBO.

Clinical Features of Ischemic Enteritis Diagnosed by Double-Balloon Endoscopy

INTRODUCTION

Ischemic enteritis (IE) is a relatively rare small bowel disease that is diagnosed via double-balloon endoscopy (DBE), although the lack of established diagnostic criteria can make it difficult to confirm the diagnosis. This study aimed to describe the clinical characteristics, endoscopic imaging features, and treatments for IE at our center. Patients and Methods. We retrospectively searched the DBE database (1,521 patients) at Nagoya University Hospital for patients with IE and collected data regarding endoscopic findings, clinical background, and histological findings. The cases were categorized according to whether they involved transient or stenotic IE.

RESULTS

The DBE database included 24 patients (14 men) with IE. Transient IE was identified in 9 patients, and stenotic IE was identified in 15. Half of the patients had a history of cerebrovascular and cardiovascular disease. A granular structure at the ulcer base was the most frequently observed DBE finding at the stenotic site. Enterography using the contrast medium revealed that transient IE had a similar stenotic lesion length, relative to stenotic IE, although stenotic IE had a significantly higher stenosis ratio (81% vs. 63%, P=0.033). Small bowel enteroclysis revealed the "lead pipe" sign (11 patients), thumbprinting (3 patients), and the serrated lumen sign (1 patient). Only 1 patient with stenotic IE experienced recurrence after conservative treatment.

CONCLUSION

During DBE, IE was characterized by cannular stenosis with extended and variable ulceration types, which spread over the edge of the stenosis, and a granular appearance at the ulcer base. These findings may help guide the diagnosis of IE.

Isolated Intestinal Ganglioneuroma Mimicking Small Bowel Crohn's Disease

Ganglioneuromas (GNs) are hamartomatous tumors derived from the autonomic nervous system. GNs are frequently associated with neurofibromatosis-1 and multiple endocrine neoplasia type 2b and commonly present with constipation, abdominal pain, weight loss, obstruction, and gastrointestinal bleeding. We report a 40-year-old man with symptoms of chronic abdominal pain, weight loss, and diarrhea for 1 year. Imaging was suggestive of thickening of ileal wall with a stricture, and subsequent biopsy revealed intestinal GN. To our knowledge, this is the first case report of an isolated intestinal GN masquerading as Crohn's disease.

Tubercular versus Crohn's ileal strictures: role of endoscopic balloon dilatation without fluoroscopy

BACKGROUND

Benign ileal strictures can cause considerable morbidity and they have been conventionally treated with surgery. The aim of this study was to report our experience of endoscopic balloon dilatation (EBD) in patients with terminal ileal strictures because of Crohn's disease and tuberculosis.

METHODS

Over the last 8 years, 9 patients (6 males; mean age 39.7±13.2 years) with benign terminal ileal strictures were treated by EBD using a colonoscope and through-the-scope controlled radial expansion balloon dilators.

RESULTS

The etiology of benign ileal stricture was Crohn's disease in 5 and tuberculosis in 4 patients. All the patients with Crohn's disease had no or partial response to 4 weeks of steroid therapy and there were no mucosal ulcerations on ileoscopy. Three patients with ileal strictures due to tuberculosis underwent dilatation after completion of the antitubercular therapy (ATT) while one patient required dilatation 3 months after starting ATT. All patients had single ileal stricture with length of stricture ranging from 0.6-1.8 cm. EBD was successful in all 9 patients with a median number of dilating sessions required of 2 (range: 1-5 sessions). Patients with Crohn's disease required more endoscopic sessions as compared to patients with tuberculosis but this difference was not statistically significant (mean number of session being 3.0±1.58 vs. 1.75±0.5 sessions respectively; P=0.1). One patient with ileal tuberculosis had enterolith proximal to the stricture that could be removed with dormia. There were no complications of the endoscopic procedure.

CONCLUSIONS

EBD is an effective, safe, and minimally invasive treatment modality for benign ileal strictures.

Intermittent obstruction resulting from multiple intestinal webs

Intestinal webs are a rare cause of bowel obstruction. A case of a 32-year-old man with multiple intestinal webs causing intermittent, partial bowel obstruction is described. The webs were initially detected with capsule endoscopy. The patient was treated with intraoperative endoscopy and balloon dilation. At early follow-up, no recurrence of his symptoms was evident.