Isolated Small Bowel Crohnʼs Disease Diagnosed by Retrograde Eneteroscopy

Abstract

Crohn's disease (CD) can occur through the entire gastrointestinal tract and in some instance can cause isolated small bowel disease which can present a diagnostic challenge A 47-year-old gentleman with history of diabetes mellitus that presented with one-month history of chronic watery non-bloody diarrhea with mild diffuse crampy abdominal pain, weight loss and progressively worsening bilateral lower limb edema and abdominal distention. He had no fever, nausea, vomiting, tenesmus or hematochezia. Examination was evident of mild diffuse abdominal tenderness with generalized anasarca. Laboratory work showed severe hypoalbuminemia with albumin of 1.9 mg/dl. Other chemistries and electrolytes were normal. He was HIV negative and stool cultures, parasitology and cryptosporidium were repeatedly negative. CT abdomen and pelvis showed diffuse small bowel wall thickening from the level of the distal jejunum to the terminal ileum with mesenteric adenopathy. Upper endoscopy and colonoscopy with terminal ileum intubation showed few gastric erosions with mild edematous colonic mucosa and no evidence of terminal ileum disease. Multiple gastric and colonic biopsies were unrevealing with negative viral, fungal and AFB cultures. He was discharged with close clinic follow up pending protein losing enteropathy workup that revealed positive fecal fat and positive anti-Saccharomyces cerevisiae antibodies. He presented 3 months later after missing clinic appointments, with similar complaint and with same lab and CT findings. Given unrevealing previous endoscopies, video capsule endoscopy was deployed showing multiple small bowel ulcers at about 63% length of small bowel with skip areas and possible strictures. Retrograde single balloon enteroscopy showed multiple medium to large size ulcers in the ileum starting at 20-25 cm from the ICV, the largest and more proximal ulcer seen appeared circumferential causing some narrowing of the lumen. Multiple biopsies were obtained showing mixed inflammatory infiltrate. Immunohistochemistry for lymphoma and special stains and cultures for AFB and fungi were negative He was discharged on oral prednisone with improvement of his symptoms on subsequent visit. Isolated small bowel involvement may be seen in up to 30% of patients with CD, making it more challenging to diagnose with routine small bowel imaging techniques. Enteroscopy and video capsule endoscopy has proven to be useful in diagnosis of isolated small bowel involvement3003_A Figure 1. Retrograde single balloon enteroscopy showed multiple medium to large size ulcers in the ileum3003_B Figure 2. CT abdomen and pelvis showed diffuse small bowel wall thickening from the level of the distal jejunum to the terminal ileum with mesenteric adenopathy. Arrows: Bowel wall thickness3003_C Figure 3. Video capsule endoscopy was deployed showing multiple small bowel ulcers at about 63% length of small bowel with skip areas and possible strictures