Terminal ileitis: a rare gastrointestinal manifestation of IgA vasculitis in a child

A girl in middle childhood was referred to the paediatric surgical team with acute colicky abdominal pain and bile-stained vomiting. This was preceded by a viral illness. Investigations revealed raised inflammatory markers, and imaging of the abdomen demonstrated ileal and jejunal thickening. Concerns were raised regarding whether she had inflammatory bowel disease. Endoscopy revealed gastritis and duodenitis, and colonoscopy was unremarkable. Video capsule endoscopy demonstrated ulcers in the jejunum and ileum.On day 8 of admission, she developed a symmetrical purpuric rash over both ankles leading to the diagnosis of Henoch-Schonlein-related ileitis. Multidisciplinary team working led to appropriate management of the patient and avoided surgery. Video capsule endoscopy enabled visualisation of the small bowel. She was managed with 5 days of methylprednisolone followed by oral steroids. She made a good recovery with no sequelae. This case highlighted that terminal ileitis is a rare complication of IgA vasculitis with a good prognosis.

Severe inflammatory ileitis resulting in ileal perforation in association with combination immune checkpoint blockade for metastatic malignant melanoma

Immune checkpoint inhibitors have become standard of care in metastatic malignant melanoma management. Despite superior effectiveness to chemotherapy, significant immune-related adverse events (irAE) may occur, particularly if used in combination. Gastrointestinal irAEs were reported with different patterns of involvement. Here, we report the case of a patient who had ileal perforation as a complication of terminal ileitis, without colitis, induced by combination immune checkpoint blockade.

[Concurrent lymphocytic colitis and microscopic enteritis in patients with chronic diarrhea]

INTRODUCTION

Lymphocytic colitis and microscopic enteritis are relatively common causes of chronic diarrhea and it is characterized by an intraepithelial lymphocytic infiltrate. There have been no previous reports of coexistence between these 2 pathologies.

OBJECTIVE

To describe histological and clinical characteristic in patients with coexistence of lymphocytic colitis and microscopic enteritis.

MATERIAL AND METHODS

All cases with simultaneous diagnosis of lymphocytic duodenosis and lymphocytic colitis were reevaluated during lapse time 2010-2016 in hospital Daniel Carrion. The slides were reviewed by 3 pathologists and clinical information was obtained from clinical records. Expression of CD3 and CD8 was detected in 6 cases by immunohistochemical assays.

RESULTS

A total of 35 patients with coexistence of lymphocytic duodenitis and lymphocytic colitis were selected of the pathology archives, 80% were females, Anemia was identified in 28.5% of patients. Blastocysitis hominis infestation was identified in 31.8%. The mean intraepithelial lymphocyte CD8 and CD3 positive was 40% in microscopic enteritis, while the mean intraepithelial lymphocyte CD3 positive was 37.2% and CD8 positive was 29.2% Additionally, lymphocytic ileitis was diagnosed in 11 of our cases. Eosinophilic colitis was diagnosed in 9 cases of lymphocytic colitis Conclusion: We found that lymphocytic colitis, microscopic enteritis and even lymphocytic ileitis can coexist in a group of patients with chronic diarrhea. These findings bring the question if this concurrence of both pathologies constituted a more generalized gastrointestinal disorder, involving both the large and the small intestines.

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.

A novel model of colitis-associated cancer in SAMP1/YitFc mice with Crohn's disease-like ileitis

Patients with inflammatory bowel disease (IBD) are at increased risk for developing colorectal cancer. Evidence suggests that colonic dysplasia and colitis-associated cancer (CAC) are often linked to repeated cycles of epithelial cell injury and repair in the context of chronic production of inflammatory cytokines. Several mouse models of CAC have been proposed, including chemical induction through exposure to dextran sulfate sodium (DSS) with the genotoxic agents azoxymethane (AOM), 1,2-dymethylhydrazine (DHM) or targeted genetic mutations. However, such models are usually performed on healthy animals that usually lack the underlying genetic predisposition, immunological dysfunction and dysbiosis characteristic of IBD. We have previously shown that inbred SAMP1/YitFc (SAMP) mice develop a progressive Crohn’s disease (CD)-like ileitis in the absence of spontaneous colitis. We hypothesize that SAMP mice may be more susceptible to colonic tumorigenesis due to their predisposition to IBD. To test this hypothesis, we administered AOM/DSS to IBD-prone SAMP and their non-inflamed parental control strain, AKR mice. Our results showed that AOM/DSS treatment enhanced the susceptibility of colitis in SAMP compared to AKR mice, as assessed by endoscopic and histologic inflammatory scores, daily weight loss and disease activity index (DAI), during and after DSS administration. SAMP mice also showed increased colonic tumorigenesis, resulting in the occurrence of intramucosal carcinoma and a higher incidence of high-grade dysplasia and tumor burden. These phenomena occurred even in the absence of AOM and only upon repeated cycles of DSS. Taken together, our data demonstrate a heightened susceptibility to colonic inflammation and tumorigenesis in AOM/DSS-treated SAMP mice with CD-like ileitis. This novel model represents a useful tool to investigate relevant mechanisms of CAC, as well as for pre-clinical testing of potential IBD and colon cancer therapeutics.

Fatal Campylobacter jejuni ileocolitis

Campylobacter infection usually starts in the jejunum and ileum and progresses distally. The case fatality rate is low and most occur in elderly or patients with comorbidity as in this case. Antibiotics should be used in severe cases or patients at risk. The choices are macrolides and fluoroquinolones. However, in some countries quinolone resistance is increasing, as in Spain. We shouldn´t forget this fact for the proper treatment approach and specifically in refractory cases.

Usefulness of Small Intestinal Endoscopy in a Case of Adult-onset Familial Mediterranean Fever Associated with Jejunoileitis

A 66-year-old Japanese man consulted our institution due to paroxysmal and repetitive bouts of fever and abdominal pain that had persisted for more than one week. Capsule and double-balloon endoscopy (DBE) showed petal-shaped mucosal redness with white hemming in the jejunum and ileum, and histopathology of the biopsy specimens revealed villous atrophy and cryptitis with extensive severe neutrophil infiltration. A genetic examination disclosed compound heterozygous MEFV mutations (E84K, P369S), and familial Mediterranean fever was diagnosed. Treatment with colchicine and infliximab was very effective in inducing the complete disappearance of symptoms and normalization of the endoscopic findings. To the best of our knowledge, this is the first report to describe the findings of small intestinal endoscopic images obtained using capsule and DBE.

Distal ileal necrosis: right ileo-colic intussuscepted anastomosis as an alternative to ileostomy

INTRODUCTION

The technique of ileo-right colic intussuscepted anastomosis creating a neo-ileo-colic valve, was first described by Ribault in 1989 and has been shown to be of value in patients with typhoid ileal perforation as well as in other non-cancerous lesions of the terminal ileum. This technique is simple and rapid, and avoids ileostomy and/or ileo-cecal resection. The goal of this case-series was to describe the technique of ileo-right colic intussuscepted anastomosis as an alternative to ileostomy.

PATIENTS AND METHODS

This is a retrospective, monocenter study of patients with lesions of the terminal ileum who were managed with right ileo-colic intussuscepted anastomosis between January 2008 and December 2013. The technique was standardized. The main outcome criterion was the post-operative complication rate.

RESULTS

Four patients, three female and one male, with a median age of 35 years were managed with ileo-right colic intussuscepted anastomosis for necrosis of the terminal ileum. The cause of distal ileal necrosis was necrosis secondary to tubo-ovarian abscess and perforation secondary to non-specific ileitis, in one patient each, and band-related bowel obstruction with extended necrosis in two patients. There was no reported post-operative morbidity or mortality and, in particular, no post-operative anastomotic leak occurred.

CONCLUSION

Based on the findings in the literature and our series, right ileo-colic intussuscepted anastomosis is a simple technique, easy to learn and associated with little morbidity. These advantages underscore the need to be aware of this technique, which is particularly useful in countries where creation of an ileostomy is problematic.

[Case of ischemic ileitis complicated by portal venous gas]

A 65-year-old woman was admitted with sudden-onset abdominal pain. Abdominal computed tomography revealed hepatic portal venous gas. Physical and laboratory examination suggested that a conservative approach was appropriate; however, 4 days later, the pain recurred and severe ischemic enteritis was diagnosed. A stenosis was identified 60 cm distal to the start of the ileum, and partial resection of the small intestine was performed. The diagnosis of ischemic enteritis was confirmed. Ischemic enteritis affecting the small intestine is uncommon, and enteritis causing intestinal stenosis with hepatic portal vein gas is even rarer.

A case of cryptogenic multifocal ulcerous stenosing enteritis: differential diagnosis from Crohn's disease

Cryptogenic multifocal ulcerous stenosing enteritis is a rare idiopathic disease of the small bowel. Its origin and pathophysiology have not been established. Clinicopathologic features include unexplained small bowel strictures with superficial ulceration, chronic or relapsing occlusion episodes. A 44-year-old man complained of recurrent colicky abdominal pain and dizziness. Laboratory tests indicated iron-deficiency anemia. There was no evidence of bleeding on esophagogastroduodenoscopic and colonofiberscopic examination. With capsule endoscopy, multiple mucosal ulcers were visualized in the jejunoileal area. A small-bowel series revealed severe strictures and the capsule was retained in the stenotic focus without obstructive symptoms. Small bowel segmental resection with end-to-end anastomosis was performed, and the histologic examination indicated cryptogenic multifocal ulcerous stenosing enteritis. After surgery, the patient's symptoms were completely resolved and his anemia was corrected. Cryptogenic multifocal ulcerous stenosing enteritis should be considered in cases of chronic or recurrent occlusion events and multiple small intestinal ulcers and strictures of unknown origin.

MIF participates in Toxoplasma gondii-induced pathology following oral infection

Background

Macrophage migration inhibitory factor (MIF) is essential for controlling parasite burden and survival in a model of systemic Toxoplasma gondii infection. Peroral T. gondii infection induces small intestine necrosis and death in susceptible hosts, and in many aspects resembles inflammatory bowel disease (IBD). Considering the critical role of MIF in the pathogenesis of IBD, we hypothesized that MIF participates in the inflammatory response induced by oral infection with T. gondii.

Methodology/Principal Findings

Mif deficient (Mif⁻/⁻) and wild-type mice in the C57Bl/6 background were orally infected with T. gondii strain ME49. Mif⁻/⁻ mice had reduced lethality, ileal inflammation and tissue damage despite of an increased intestinal parasite load compared to wt mice. Lack of MIF caused a reduction of TNF-α, IL-12, IFN-γ and IL-23 and an increased expression of IL-22 in ileal mucosa. Moreover, suppressed pro-inflammatory responses at the ileal mucosa observed in Mif⁻/⁻ mice was not due to upregulation of IL-4, IL-10 or TGF-β. MIF also affected the expression of matrix metalloproteinase-9 (MMP-9) but not MMP-2 in the intestine of infected mice. Signs of systemic inflammation including the increased concentrations of inflammatory cytokines in the plasma and liver damage were less pronounced in Mif⁻/⁻ mice compared to wild-type mice.

Conclusion/Significance

In conclusion, our data suggested that in susceptible hosts MIF controls T. gondii infection with the cost of increasing local and systemic inflammation, tissue damage and death.

[Immunocompromised HIV patient with lymphadenopathy and fever]

The case of a immunocompromised HIV patient with fever and lymphadenopathy discussed in an anatomo-pathological round. This complex clinical case was used as an opportunity to discuss the broad differential diagnosis of fever in an immunocompromized individual with multiples lymphadenopathies. Clinical reasoning leading to the probable diagnosis based on clinical, biological and radiological informations is not only a difficult task for the speaker but also a rich source of learning opportunities for our medical community.

[Collagenous gastritis and ileo-colitis occurred in autoimmune context: report of a case and review of the literature]

Collagenous colitis belongs to the group of microscopic colitis. The aetiology and pathogenesis are unknown but different pathogenic hypothesis, autoimmune, infectious, alimentary and medicinal being are advanced, the last one being the most frequent aetiology. The collagenous gastritis is a rare entity and its association with collagenous colitis was exceptionally reported, only six cases being published. We report the seventh case of collagenous gastritis, ileitis and colitis in a 75-year-old woman with chronic diarrhea and important weight loss. This thickened subepithelial collagen band was appeared in an autoimmune injury context with antecedent of Hashimoto's thyroiditis and probably chronic atrophic Biermer's gastritis. The clinical and histological evolution was favourable with budesonide.

Proximal extension of backwash ileitis in ulcerative-colitis - associated colon cancer

BACKGROUND

Extension of the inflammatory process into the terminal ileum in ulcerative colitis is termed backwash ileitis. Ulcerative colitis patients with pancolitis and backwash ileitis may be at increased risk of colorectal carcinoma. A case of ulcerative colitis-associated cancer with backwash ileitis, which extended proximally over time, is described.

CASE REPORT

A 67-year-old man was diagnosed with pancolitis; despite prednisolone and mesalazine treatment, he showed no improvement. Although initial endoscopic examination showed no abnormalities in the terminal ileum, a repeat colonoscopy 4 months later revealed erythema, absence of the vascular pattern, mucosal friability, and erosions within 30 cm of the terminal ileum in a continuous fashion from the cecum, and a flat, elevated lesion was found in the transverse colon. On histopathologic examination, the patient had nonspecific, active, chronic inflammation of the ileal mucosa, consistent with backwash ileitis, and colonic adenocarcinoma. Despite additional treatment with leukocytapheresis, the backwash ileitis progressed, with increased severity of mucosal inflammation and extensive erosions, 20 cm proximal to the primarily affected site of the ileum on repeat colonoscopy 2 months later. The patient underwent a proctocolectomy and excision of the terminal ileum with an ileostomy.

CONCLUSIONS

Histopathology of the surgical specimen revealed marked backwash ileitis and submucosal, well-differentiated adenocarcinoma. The patient has remained well for 5 years after surgery.

[Microscopic ileitis as a cause of chronic diarrhea: study of cases and controls]

INTRODUCTION

To observe microscopically the ileal mucosa invaded by lymphomononuclear in patients with chronic diarrhea, despite of normality of its endoscopic aspect leaded to name this discovery as microscopic ileitis. This investigation look answer to the question: is the microscopic ileitis associated to chronic diarrhea?

MATERIAL AND METHODS

Microscopic ileitis was looked for in 30 patients with chronic diarrhea and 30 without it, using cases controls design matched up according to sex and age with pathologist and endoscopists blinded to participant's condition. The OR was calculated by means of conditioned logistical regression. Additionally, sanguine mensurations of folic acid and B12 vitamin were made as signalers of malabsorption intestinal segment.

RESULTS

Microscopic ileitis was found in 27 of 30 cases and in 6 of 30 controls. The statistical analysis found an OR 21 [IC 95% 2,83-156.1] p = 0,003. The cases showed subnormal folic acid average but B12 vitamin was normal. CONCLUSION The microscopic ileitis is strongly associated and in a very probably causal way to the chronic diarrhea. The microscopic ileitis would express the concurrence of various processes initiated for a sympathetic over activity that, promoting the epithelial functional collapse, origins malabsortive chronic diarrhea.

Meta-analysis: colorectal and small bowel cancer risk in patients with Crohn's disease

BACKGROUND

Crohn's disease is associated with small bowel cancer whilst risk of colorectal cancer is less clear.

AIM

To ascertain the combined estimates of relative risk of these cancers in Crohn's disease.

METHODS

MEDLINE was searched to identify relevant papers. Exploding references identified additional publications. When two papers reviewed the same cohort, the later study was used.

RESULTS

Meta-analysis showed overall colorectal cancer relative risk in Crohn's disease as 2.5 (1.3-4.7), 4.5 (1.3-14.9) for patients with colonic disease and 1.1 (0.8-1.5) in ileal disease. Meta-regression showed reduction in relative risk over the past 30 years. Subgroup analysis showed Scandinavia had significantly lower colorectal cancer relative risk than the UK and North America. Cumulative risk analysis showed 10 years following diagnosis of Crohn's disease relative risk of colorectal cancer is 2.9% (1.5%-5.3%). Meta-analysis showed small bowel cancer relative risk in Crohn's disease is 33.2 (15.9-60.9). Small bowel cancer relative risk has not significantly reduced over the last 30 years.

CONCLUSION

Relative risk of colorectal and small bowel cancers are significantly raised in Crohn's disease. Cumulative risk of colorectal cancer of 2.9% at 10 years suggests a potential benefit from routine screening. However, the value of screening requires rigorous appraisal.

The significance of ileo-colonic lymphoid nodular hyperplasia in children with autistic spectrum disorder

BACKGROUND

Intestinal mucosal pathology, characterized by ileo-colonic lymphoid nodular hyperplasia (LNH) and mild acute and chronic inflammation of the colorectum, small bowel and stomach, has been reported in children with autistic spectrum disorder (ASD).

AIM

To assess ileo-colonic LNH in ASD and control children and to test the hypothesis that there is an association between ileo-colonic LNH and ASD in children.

PATIENTS AND METHODS

One hundred and forty-eight consecutive children with ASD (median age 6 years; range 2-16; 127 male) with gastrointestinal symptoms were investigated by ileo-colonoscopy. Macroscopic and histological features were scored and compared with 30 developmentally normal (non-inflammatory bowel disease, non-coeliac disease) controls (median age 7 years; range 1-11; 25 male) showing mild non-specific colitis in 16 cases (13 male) and normal colonic histology in 14 cases (12 male). Seventy-four ASD children and 23 controls also underwent upper gastrointestinal endoscopy. The influence on ileal LNH of dietary restriction, age at colonoscopy, and co-existent LNH elsewhere in the intestine, was examined.

RESULTS

The prevalence of LNH was significantly greater in ASD children compared with controls in the ileum (129/144 (90%) vs. 8/27 (30%), P < 0.0001) and colon (88/148 (59%) vs. 7/30 (23%), P = 0.0003), whether or not controls had co-existent colonic inflammation. The severity of ileal LNH was significantly greater in ASD children compared with controls, with moderate to severe ileal LNH present in 98 of 144 (68%) ASD children versus 4 of 27 (15%) controls (P < 0.0001). Severe ileal LNH was associated with co-existent colonic LNH in ASD children (P = 0.01). The presence and severity of ileal LNH was not influenced by either diet or age at colonoscopy (P = 0.2). Isolated ileal LNH without evidence of pathology elsewhere in the intestine was a rare event, occurring in less than 3% of children overall. On histopathological examination, hyperplastic lymphoid follicles are significantly more prevalent in the ileum of ASD children (84/138; 61%) compared with controls (2/23; 9%, P = 0.0001).

CONCLUSION

Ileo-colonic LNH is a characteristic pathological finding in children with ASD and gastrointestinal symptoms, and is associated with mucosal inflammation. Differences in age at colonoscopy and diet do not account for these changes. The data support the hypothesis that LNH is a significant pathological finding in ASD children.

Obstructive fibrostenotic Crohn's disease

Crohn's disease is often complicated by gastrointestinal strictures. Postoperative recurrence at the anastomotic site is common and repeated surgical interventions may be necessary. Medical treatment may relieve active inflammation (see chapter on active luminal disease) but fibrous strictures will not respond to this. Mechanical treatment methods consist of endoscopic balloon dilation, stricturoplasty or surgical resection. Fibrostenotic Crohn's disease does not respond to medical therapy and requires endoscopic or surgical treatment.

Histologic predictors of pouchitis in patients with chronic ulcerative colitis

Inflammation of ileal reservoir mucosa ("pouchitis") is a common sequelae in ulcerative colitis (UC) patients who have had a colectomy with ileal pouch anal-anastomosis (IPAA). Although several clinical, genetic, and laboratory parameters have been evaluated, reliable pathologic predictors for the development of pouchitis are lacking. The purpose of this case-control study was to determine whether there are any pathologic features in UC colectomy specimens that may help predict the subsequent development of pouchitis after an IPAA procedure. The study group consisted of 39 UC patients (male/female ratio: 21/18, mean age: 35 years), who had at least 1 episode of pouchitis after an IPAA procedure during the follow-up period (mean: 57 months, range: 12-121 months). There were 26 control patients (male/female ratio: 11/15, mean age: 37 years), all of whom also underwent a total colectomy and IPAA procedure for UC, but did not develop pouchitis during the follow-up period (mean: 78 months, range: 14-223 months). Routinely processed tissues from each colectomy specimen were evaluated for a variety of histologic features, such as extent of colitis, severity of colitis, extent of severe colitis, type and extent of ulceration, presence and severity of appendiceal inflammation, and the presence of active ileitis, and compared between the study and control patients. Pathologic features that were associated with the subsequent development of pouchitis included the presence of severe colitis that extended into the cecum (severe pancolitis), which was present in 7/39 (18%) pouchitis patients, but in none (0%) of the control patients (P = 0.03), early fissuring ulcers [9/39 (23%) pouchitis cases versus 1/26 (4%) controls (P = 0.04)], active inflammation of the appendix [20/32 (63%) pouchitis patients versus 7/19 (31%) controls (P = 0.03)], and appendiceal ulceration [13/32 (41%) pouchitis patients versus none (0%) of the controls (P = 0.002)]. No significant differences in patient gender or age, depth or extent of ulceration, or the presence or absence of "backwash ileitis" were identified between the 2 groups. In conclusion, there are several histologic features in colectomy specimens from UC patients who have undergone an IPAA procedure that may help predict the subsequent development of pouchitis. Of these features, appendiceal ulceration is highly associated with pouchitis.

[Polymicrobial sepsis and perityphlic abscess: case report and review of literature]

AIM

To evaluate the safety and efficacy of conservative therapy of polymicrobial anaerobic sepsis and appendiceal mass.

CASE REPORT

We report on an 18-year-old patient admitted for fever (38.8 degrees C), abdominal pain and vomiting. Leukocytosis with left shift maturation, and diarrhea were noted during hospital stay. A Fusobacterium species and Bacteroides ovatus were isolated from blood culture specimens. Radiologic examination with barium enema showed normal ileocecal region, while colonoscopy indicated terminal ileitis. Abdominal ultrasound and computed tomography showed appendiceal mass sized 6.5x5.5 cm in the right lower quadrant. The patient was treated with intravenous antibiotic therapy consisting of amoxicillin + clavulanic acid and metronidazole for 21 days. He was discharged from the hospital when control ultrasound indicated disappearance of the appendiceal mass.

DISCUSSION

Acute appendicitis is the most common cause of urgent surgery in children. Bacterial enteritis limited to the ileocecal region appears to be responsible for an appreciable number of unnecessary appendectomies. On the other hand, diagnostic errors in appendicitis may delay early appendectomy and result in the formation of appendiceal mass. The advent of high-resolution real-time scanners and graded compression sonography has enabled not only an accurate diagnosis of acute appendicitis but also a reliable diagnosis of other diseases of the ileocecal region. Acute terminal ileitis has similar clinical and laboratory manifestations as acute appendicitis, thus presenting a common diagnostic problem in daily practice. Perforation occurs in 20% to 30% of children with acute appendicitis. Perforation may be difficult to diagnose by sonography. The most common complications are peritonitis and intraperitoneal abscesses. The management of appendiceal mass remains controversial, such as interval appendectomy after nonoperative treatment.

CONCLUSION

Successful conservative treatment for polymicrobial anaerobic sepsis and appendiceal mass in an 18-year-old patient is described. The case report is followed by review of the literature on the appendiceal mass management.

Cholecystectomy in patients with Crohn's ileitis

PURPOSE

Gallstone disease is reported to be higher in patients with Crohn's disease than in the general population. This study was designed to determine the prevalence of cholecystectomy in patients with Crohn's ileitis, attempt to identify any associated risk factors, and determine whether it is justified to perform prophylactic cholecystectomy during ileocolic resection.

METHODS

A total of 191 patients with Crohn's ileitis who were treated medically or who had an ileocolic resection were retrospective reviewed. A questionnaire survey was performed. Telephone interviews were conducted for the non respondents. Further review of medical records was performed to determine the details of admissions for any gallstone disease and/or subsequent cholecystectomy. A control group matched for age and gender was obtained.

RESULTS

A total of 191 questionnaires were mailed, and the overall response rate was 70.2 percent (134/191) after telephone interview follow-up. There were 2 of 45 medical and 18 of 89 surgical patients with symptomatic cholelithiasis, i.e., 14.9 percent (20/134) of respondents. As a result, 2 patients (1.5 percent) required endoscopic sphincterotomy, 17 patients (12.7 percent) needed cholecystectomy, and 1 patient (0.7 percent) did not have any intervention. Only five patients had a cholecystectomy after their ileal resections. In the control group of 150 patients, 15 patients (14 females; mean age, 51.9 years; range, 34-78 years) had previous cholecystectomy. There was no significant difference with prevalence of cholecystectomy in Crohn's patients compared with controls (17/134 vs. 15/150; P = not significant). Furthermore, the number of ileal resections did not affect the cholecystectomy rate, but patients who had >30 cm of ileum resected were more likely to have cholecystectomy (P = 0.056).

CONCLUSIONS

The prevalence of gallstone disease in Crohn's ileitis requiring cholecystectomy is similar to that of the general population with a female predominance. In addition, the number of patients requiring cholecystectomy after ileal resection was low. Thus, synchronous prophylactic cholecystectomy during ileocolic resection for Crohn's ileitis is not justified.

Tuberculous ileitis in a renal transplant recipient with familial Mediterranean fever: Gray-scale and power Doppler sonographic findings

The ileocecal area is the most common site of involvement of intestinal tuberculosis. We report the case of a 26-year-old renal transplant recipient with familial Mediterranean fever who developed tuberculous ileitis. Gray-scale sonography and CT showed circumferential thickening of the bowel wall and enlargement of the mesenteric lymph nodes. Power Doppler sonography revealed markedly increased vascularity in the wall of the affected ileal segment and in the mesenteric nodes. Some nodes had no flow at the center owing to caseation necrosis, a finding consistent with the diagnosis of tuberculous ileitis. Colonoscopy was performed, and histopathologic examination of biopsy specimens revealed acute inflammatory changes. Cultures of the specimens confirmed the presence of Mycobacterium tuberculosis. We conclude that findings on power Doppler sonography may support a diagnosis of tuberculous ileitis and avoid clinical mismanagement.

Intestinal Wegener's granulomatosis in a patient with severe alpha-1-antitrypsin deficiency resulting from a unique combination of two deficiency alleles (PiZ and PiMProcida)

Alpha-1-antitripsyn neutralizes the tissue damaging effects of proteases. Alpha-1-antitripsyn deficiency manifests with necrotizing vasculitis. Wegener's granulomatosis is a systemic necrotizing vasculitis that uncommonly affects the gut. The molecular genetics of patients with Wegener's granulomatosis of the gastrointestinal tract have never been characterized. A 63-year-old man with emphysema was admitted with a fever of unknown origin. Initially, this fever was linked to ileocolic Crohn's disease and later attributed to antineutrophil cytoplasm antibody-positive systemic vasculitis. Genetic analysis revealed that the alpha-1-antitripsyn deficiency was due to a previously unreported compound heterozygosity for two mutations (PiZ and PiMProcida). Our findings appear to support the concept that severe alpha-1-antitripsyn deficiency is implicated in the pathogenesis of the Crohn's disease-like milder intestinal manifestations belonging to the spectrum of Wegener's granulomatosis.

Ultrasound of acute GI tract conditions

Patients with acute abdominal pain are a great challenge to the radiologist. The clinical diagnosis is classically unreliable, resulting in both negative laparotomies as well as ill-advised surgical delay in a large number of patients. Ultrasound offers a non-invasive way to decrease both false-negative and false-positive diagnoses in this category of patients. This article focuses on the role of sonography in the diagnosis of acute conditions of the gastrointestinal tract tract such as appendicitis, sigmoid diverticulitis, Crohn's disease, colitis, infectious ileocecitis caused by Yersinia, Campylobacter or Salmonella, right-sided colonic diverticulitis, bowel malignancy presenting acutely, small bowel obstruction, intussusception, omental infarction, and epiploic appendagitis. The sonographic spectrum of these conditions as well as possible pitfalls are discussed using illustrative case histories.

Necrotizing ileitis caused by cytomegalovirus in patient with systemic lupus erythematosus: case report

We report a systemic lupus erythematosus (SLE) patient with necrotizing ileitis diagnosed at a tertially care centre in Thailand. The patient was surgically explored because peritonitis was suspected and segmental gangrenous and perforation of the terminal iliem were found. The pathological finding was necrotizing ileitis with appearance of cytomegalic intranuclear inclusion body. The presence of cytomegalovirus (CMV) infection in tissue was confirmed by CMV-DNA detection using polymerase chain reaction and ELISA probe hybridization method. The hemoculture and peritoneal fluid culture results revealed no pathogenic organisms. Postoperatively, the clinical course of the patient deteriorated and she developed hypotension. Vasopressive drugs were administered without clinical improvement. She expired on day 5 postoperation. Regarding CMV infection, the organism involves the small bowel in only 4.3 per cent of all CMV infections of the gastrointestinal tract. Isolated cases of ileal perforation due to CMV infection have never been reported in a SLE patient. Thus, chronic right lower abdominal pain, fever with or without diarrhea in immunocompromised patients should cause clinicians to consider CMV ileitis in the differential diagnosis. Immediate surgical resection and prompt antiviral therapy lead to successful treatment.

[Ulcerative ileocolitis induced by NSAID therapy]

HISTORY AND PHYSICAL EXAMINATION

A 67-year-old woman was admitted to our hospital for spasmodic abdominal pain, diarrhea, and general weakness. She had lost 5 kg of weight over the past few weeks. The patient had a 20-year history of chronic analgetic abuse, mainly consuming over-the-counter nonsteroidal anti-inflammatory drugs (NSAID).

EXAMINATION

Laboratory examination was remarkable for a low serum albumin (2.3 g/dl), an increased erythrocyte sedimentation rate of 70 mm/h, and a profound anemia of 8.5 g/dl. Ultrasound of the abdomen showed thickening of the colonic wall and distended colon loops filled with fluid. On colonoscopy several ulcerations from the sigmoid to the ileum were seen. Histologic examination showed a nonspecific ileocolitis.

DIAGNOSIS, THERAPY AND CLINICAL COURSE

After cessation of NSAID intake diarrhea stopped within a few days. Abdominal pain resolved, anemia improved and the patient gained weight. A second colonoscopy revealed healing of the colonic ulcerations. Additional examinations regarding differential diagnoses showed no pathological results. Clinical course and subsequent clinical and endoscopic controls revealing further improvement confirmed the diagnosis of an NSAID-induced ileocolitis.

CONCLUSION

This patient is a typical example for NSAID-induced colonic ulcerations. It should be recognized that NSAID induce ulcers not only in the upper gastrointestinal tract. A careful drug history may provide the clue for the cause of lower gastrointestinal tract ulcerations.

Backwash ileitis is strongly associated with colorectal carcinoma in ulcerative colitis

BACKGROUND & AIMS

Commonly accepted risk factors for colorectal carcinoma (CRC) in ulcerative colitis are duration and extent of disease. By identifying still unknown risk factors, surveillance strategies may be improved further. We investigated whether backwash ileitis is also a factor associated with CRC in ulcerative colitis.

METHODS

Five hundred ninety consecutive patients with ulcerative colitis who received restorative proctocolectomy were classified into 3 groups: (1) pancolitis with backwash ileitis, (2) pancolitis without backwash ileitis, and (3) left-sided colitis. The association with CRC was analyzed in these 3 groups of patients. As further risk factors, we investigated disease duration, dysplasia, primary sclerosing cholangitis, age at diagnosis of disease, disease activity, and gender. Univariate and multivariate logistic regression were used for analysis.

RESULTS

CRC was diagnosed in 11.2% of all patients. CRC was found in 29.0% of 107 patients in group 1, compared with 9.0% of 369 patients in group 2, and in 1.8% of 114 patients in group 3 (P < 0.001). Cancer patients in group 1 showed significantly more multiple tumor growth (45.2%) than patients in group 2 (24.2%) and group 3 (0%) (P = 0.041). Estimating the relative risk for CRC in the multivariate analysis, patients in group 1 showed a significantly higher odds ratio than patients in groups 2 and 3 (odds ratio: 19.36 vs. 9.58 vs. 1; P < 0.001). High-grade dysplasia, low-grade dysplasia, disease duration of more than 10 years, and disease duration of less than 10 years in patients older than 45 years were further factors with significantly increased risk (odds ratios: 21.69, 6.36, 3.63, 4.37), but primary sclerosing cholangitis was not (P = 0.080). However, primary sclerosing cholangitis was strongly associated with backwash ileitis.

CONCLUSIONS

There is a strong association of backwash ileitis with CRC in patients with ulcerative colitis who undergo proctocolectomy. The predictive value of backwash ileitis for CRC and premalignant dysplasia in patients with ulcerative colitis should be investigated in future studies based on colonoscopic surveillance.

Primary Epstein-Barr virus-associated Hodgkin disease of the ileum complicating Crohn disease

We describe a case of primary Hodgkin disease of the terminal ileum in a 38-year-old man with Crohn disease of 24 years' duration. The infiltrate was located in an ulcerated fistula involving the terminal ileum and urinary bladder. Reed-Sternberg cells and their variants were characteristically positive for CD15, fascin, and CD30 and showed focal positivity for CD20. Epstein-Barr virus messenger RNA was also detected in the neoplastic cells. Staging revealed no evidence of other lymph node or organ involvement. Although rare, primary gastrointestinal Hodgkin disease arising in the setting of Crohn disease may have a stronger association with Epstein-Barr virus infection than conventional Hodgkin disease.