Intestinal occlusion due to cryptogenic, multifocal, ulcerous, stenosing enteritis treated by laparoscopy

Abstract

Background: Cryptogenic multifocal ulcerous stenosing enteritis (CMUSE) is characterized by stenotic zones and multiple mucosal ulcerations in the small bowel. The diagnosis is clinical and histopathological based on the history of periodic attacks of intestinal obstruction, vomiting and abdominal pain. According to our knowledge, this is the only report of treatment of CMUSE via laparoscopy. Case Presentation: A 47-year-old man arrived to the emergency room with intense colicky pain initiated 24 hours before arrival, accompanied by nausea, gastrobiliary vomiting, constipation and inability to pass flatus. Physical examination revealed abdominal distension, generalized abdominal tenderness to palpation, peristalsis with metallic tone, no signs of peritoneal irritation, and extremities with mild edema. Laboratory exams showed hyperglycemia, hyponatremia and hypoalbuminemia. Plain abdominal X rays reveled dilated loops of small bowel and fluid levels mainly on the left hemiabdomen, suggesting mechanical ileus. No evidence of free air in the abdomen was found. Intravenous fluids and electrolyte replacement was initiated and a nasogastric tube was inserted for decompression. Medical management failed to improve the symptoms after 24 hours, so an exploratory laparotomy was performed. The affected segment was resected laparoscopically. Pathology reported multiple sites of ulceration concerning the mucosae and submucosae, myenteric plexus hypertrophy and pseudo pyloric gland metaplasia. Multiple eosinophils and neutrophils were detected. Patient was discharged from the hospital on the fifth postoperative day and started with prednisolone 30mg/day for 3 months. Three years after he has not had any other episode of intestinal obstruction. Conclusion: Diagnosis of CMUSE must be considered in cases of repeated attacks of small bowel obstruction and when stenotic areas and superficial ulcers are found. Laparoscopic surgery should be considered in patients with repeated attacks of intestinal obstruction and in whom CMUSE is suspected because it permits a diagnosis and resection of the affected segments with the advantages on the minimal invasive surgery.