Celiac Disease Presenting as a Cecal Bascule

Abstract

Background: The prevalence of celiac disease is as high as 1%, but many cases remain undiagnosed. In a large European survey, the ratio of diagnosed to undiagnosed was as high as 1 to 7, demonstrating the largely accepted “celiac iceberg” effect. Rarely, celiac disease can present as obstruction caused by malignancy, ulcerative jejuno-ileitis, intussusception or pseudo-obstruction. Such clinical presentations require high clinical suspicion. To improve diagnosis and prevent complications of celiac disease, it is imperative that we increase awareness of the disease and its varied presentations. We present a case of a cecal bascule requiring operative management and complicated by multiple partial small bowel obstructions, preceding a diagnosis of celiac disease. Results: A twenty-eight year-old Caucasian woman with recently diagnosed iron deficiency anemia (Hgb 8.2, Ferritin 2, MCV 65) of unknown etiology on oral iron therapy presented to the emergency room with diffuse abdominal pain of acute onset. She reported a few month history of mild abdominal cramps and episodes of bloating after meals, in addition to ongoing fatigue despite oral iron therapy. CT scan revealed a cecal bascule for which the patient underwent a right hemi-colectomy. The patient developed an ileus on post-op day five requiring nasogastric decompression for forty-eight hours. She was discharged home on post-op day eight, tolerating a regular diet. Further work-up performed for the previously identified iron deficiency anemia revealed positive celiac serologies. The patient continued a normal gluten-containing diet pending endoscopy. Two weeks later, she developed a partial bowel obstruction which was managed conservatively with bowel rest. Endoscopy performed after resolution of the obstruction confirmed the diagnosis of celiac disease. Despite compliance with a gluten-free diet, she developed another partial bowel obstruction which was again managed conservatively with bowel rest. At the time of this case report, the patient is now seven months post-op, maintaining a strict gluten-free diet and doing well. Conclusion: The clinical presentations of celiac disease are highly variable, some cases presenting as clinically silent to more serious cases such as obstruction requiring surgical intervention. Diagnostic delay can result in significant complications, unnecessary hospitalizations, and emergent surgical procedures. To prevent complications, clinicians should have a high index of suspicion for celiac disease when evaluating patients with obstructive bowel symptoms, especially in cases where the etiology of obstruction is unknown.