Severe Abdominal Pain in the Setting of an Intestinal Intussusception as a First Presentation of Celiac Disease

Abstract

A 36-year-old woman with Hashimoto thyroiditis, anxiety, and a history of two pregnancies by C- section complicated by hyperemesis gravidarum requiring total parenteral nutrition (TPN), as well as previous idiopathic chronic urticarial, presented to the hospital with severe periumbilical pain. The pain started 4 days prior and was associated with watery non-bloody diarrhea, nausea, and non-bilious non-bloody vomiting. The pain was described as cramping and sharp pain that lasted minutes, over a background of continuous dull pain located in the periumbilical region. On examination, the patient was afebrile, with a normal respiratory and heart rate. Cardiovascular and pulmonary exam was unremarkable. Abdominal examination revealed periumbilical tenderness without guarding or rebound tenderness, and normal bowel sounds. Blood work revealed leukocytosis of 13.4 thousand/uL with a neutrophil predominance of 87%, mild anion gap of 17 with low bicarbonate level of 11.5 mmol/L. Computer tomography (CT) of the abdomen and pelvis with oral contrast showed evidence of ileoileal intussusception and extensive prominent abdominal lymphadenopathy. The patient underwent an exploratory laparoscopy that revealed no intussusception, but evidence of reactive lymphadenopathy that was sampled. Stool cultures, Clostridium difficile, ova and parasite cultures and Cryptosporidium antigen were negative. The patient's course was complicated by poor oral intake, nausea, vomiting and abdominal pain. She underwent multiple repeat imaging studies including magnetic resonance enterography and CT angiography, as well as esophagogastroduodenoscopy, enteroscopy and colonoscopy that revealed diffuse absence of villi and significant crypt hyperplasia consistent with Celiac sprue. Tissue transglutaminase IgA was also found to be elevated to 254.6 CU. She was started on a gluten free diet with persistence of symptoms. Subsequently she was treated with prednisone, and eventually required TPN with improvement of abdominal pain albeit not complete disappearance. Conclusion: Intestinal intussusception as a first presentation of celiac disease.