Intest Res.  2016 Jan;14(1):89-95. 10.5217/ir.2016.14.1.89.

Ischemic enteritis with intestinal stenosis

• Koshikawa
• Nakase H
• Matsuura M
• Yoshino T
• Honzawa Y
• Minami N
• Yamada S
• Yasuhara Y
• Fujii S
• Kusaka T
• Manaka D
• Kokuryu H

• KMID: 2174515
• DOI: http://doi.org/10.5217/ir.2016.14.1.89

Abstract

A 75-year-old man was admitted to our hospital with sudden onset of vomiting and abdominal distension. The patient was taking medication for arrhythmia. Computed tomography showed stenosis of the ileum and a small bowel dilatation on the oral side from the region of stenosis. A transnasal ileus tube was placed. Enteroclysis using contrast medium revealed an approximately 6-cm afferent tubular stenosis 10 cm from the terminal ileum and thumbprinting in the proximal bowel. Transanal double-balloon enteroscopy showed a circumferential shallow ulcer with a smooth margin and edema of the surrounding mucosa. The stenosis was so extensive that we could not perform endoscopic balloon dilation therapy. During hospitalization, the patient's nutritional status deteriorated. In response, we surgically resected the region of stenosis. Histologic examination revealed disappearance of the mucosal layer and transmural ulceration with marked fibrosis, especially in the submucosal layer. Hemosiderin staining revealed sideroferous cells in the submucosal layers. Based on the pathologic findings, the patient was diagnosed with ischemic enteritis. The patient's postoperative course was uneventful.

Keyword

Ischemia; Intestines; Stenosis; Double-balloon enteroscopy

MeSH Terms

Aged
Arrhythmias, Cardiac
Constriction, Pathologic*
Dilatation
Double-Balloon Enteroscopy
Edema
Enteritis*
Fibrosis
Hemosiderin
Hospitalization
Humans
Ileum
Ileus
Intestines
Ischemia
Mucous Membrane
Nutritional Status
Ulcer
Vomiting
Hemosiderin

Figure

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  Fig. 1 Radiologic findings on admission and on post-admission day 14. (A) Abdominal radiography on admission showed marked small bowel dilation. (B) Abdominal CT scan showed thickened wall of ileum and stenosis (arrow) and small bowel dilatation. (C) A small intestinal series revealed afferent tubular stenosis of ileum (yellow arrow) and thumbprinting of the oral ileum (arrow).

• 

  Fig. 2 Endoscopic findings on post-admission day 25. Double balloon enteroscopy (DBE) showed a circumferential ulcer and edematous mucosa. The endoscope could not pass through the stenosis.

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  Fig. 3 Histologic findings. (A) Macroscopic findings of the resected specimen revealed a thickened wall and ulcer (anal side is left). (B) Histologic examination revealed transmural ulceration with marked fibrosis, especially in the submucosal layer (Masson's trichrome stain: low-power field). (C) Disappearance of crypt and marked inflammatory cell infiltration in the mucosal layer (H&E: high-power field). (D) Hemosiderin staining revealed sideroferous cells in the submucosal layers.

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  Fig. 4 Proposed management flowchart for stenosis of the small intestine. An ileus tube should be placed in cases of ileus with stenosis of the small intestine. Following one to two weeks of conservative treatment, balloon-assisted enteroscopy should be performed if a definitive diagnosis remains unconfirmed after several examinations, including intestinal enteroclysis. If malignancy is confirmed by histological studies, surgical treatment should be performed. If not, endoscopic balloon dilatation may be considered for a short stenosis. A long stenosis, however, requires surgical treatment.

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