Small-Intestinal Ulcerations (original) (raw)

2016, John Wiley & Sons, Ltd eBooks

The differential diagnoses of ulcers of the small bowel are well known. They include Crohn's disease, non-steroidal antiinflammatory drugs (NSAIDs), radiation, vasculitis, medication effects, some infections, and certain neoplasms (Table 98.1). Nonetheless, when faced with the finding of ulceration in the small bowel, it can be difficult to come up with a final diagnosis. Crohn's disease is most common, but NSAID use is also frequently seen. How, then, does a physician make the diagnosis of Crohn's disease based on the presence of ulcers seen only on endoscopy, capsule or otherwise? In the past, we were confident in making the diagnosis in the clinical setting of pain and diarrhea in a young person in whom a small bowel series showed ileitis. We clearly should be able to do the same with endoscopic findings; that is, to combine the clinical scenario with the endoscopic, rather than the radiographic, findings. There can be other evidence to support a diagnosis of Crohn's, including a family history of inflammatory bowel disease (IBD) and abnormal serologies of antineutrophil cytoplasmic antibodies (ANCA) and anti-Saccharomyces cerevisiae antibodies (ASCA), though this is not the intended use of these blood tests. Endoscopic biopsy typically cannot differentiate a Crohn's ulcer from an NSAID ulcer. Other testing, such as computed tomographic (CT) scanning, generally provides no additional information beyond what is supplied by endoscopy. Grading the severity of inflammatory findings on capsule endoscopy can provide more certainty in making a final diagnosis. Case A 45-year-old female presents with a history of obscure gastrointestinal (GI) bleeding. Her first episode was at 20 years of age. Since then, multiple episodes have occurred, occasionally requiring transfusion of packed red blood cells (RBCs). Evaluations, including colonoscopy, upper endoscopy, and bleeding scan, are unrevealing. Additionally, CT scan, Meckel's scan, and small bowel series are normal. Her history is otherwise remarkable, except for rare NSAID use and hypertension, for which she takes diuretics. Capsule endoscopy is performed and discloses diffuse mucosal edema and erythema associated with scattered ulceration and luminal narrowing at the mid-ileum (Figure 98.1). These findings correlate to an activity score of 1232. Serologies of ASCA and p-ANCA are negative. Other laboratory values are unremarkable. Following the capsule exam, a double-balloon enteroscopy (DBE) from the transrectal approach is performed. Endoscopically, the area and affected regions of the small bowel are identical to the capsule study. Biopsies reveal active inflammation. The clinical history, endoscopic appearance, and biopsies are consistent with Crohn's disease.