Isolated Small Bowel Crohn’s Disease Diagnosed With Retrograde Single-Balloon Enteroscopy

Abstract

Crohn’s disease (CD) can occur throughout the entire gastrointestinal tract with the ileocecal segment being the most common site. However, CD may involve segments of the small bowel other than the ileum and isolated small bowel CD can present a diagnostic challenge. A 41-year-old Filipino female presented with recurrent, moderate to severe abdominal pain lasting for almost 11 months which later became associated with vomiting and progressive abdominal distention. Gastroscopy and colonoscopy were insignificant. CT scan of the abdomen showed diffuse long segment wall thickening of the small bowel segments at the right upper quadrant of the abdomen with focal dilatation at the distal segment. Retrograde single-balloon enteroscopy revealed stenosis at the distal jejunum/proximal ileum segment with the proximal and middle ileum exhibiting granular mucosa, blunted villi, inflammatory polyps, and multiple longitudinal aphthous ulcers. Biopsies taken were suggestive of CD. Due to signs of progressive bowel obstruction, the patient underwent laparotomy resulting in resection of the affected small bowel segment. During laparotomy, thickened segments with fat wrapping of the ileum 20 centimeters from the ileocecal junction were noted. A 64 centimeter jejunoileal segment was resected. The middle 24 cm segment was indurated with granular mucosa and obliterated mucosal folds. Histopathology showed a non-caseating granuloma with transmural inflammation up to the prevocalic fat and cryptitis. The patient did well post-operatively and infliximab infusion was started soon after discharge. She has been in remission since, having completed the 6th week of her infliximab induction therapy. Diagnosing small bowel diseases has always been a challenge before and mostly depended on radiographic imaging. Single balloon enteroscopy has proven to be useful in the diagnosis and management of isolated small bowel CD.