Aphthoid Ulcers Research Articles

P507 Can systematic upper gastrointestinal endoscopy benefit patients with Inflammatory Bowel Disease?

Abstract Background In the context of Inflammatory Bowel Disease (IBD), a comprehensive understanding of disease extent and related complications is essential for effective clinical care. While Crohn’s disease (CD) can affect the digestive tract from mouth to anus, ulcerative colitis (UC) is limited to the rectum and colon. This study investigates the potential utility of systemic gastroscopy in IBD management. Methods We conducted a retrospective cohort study using data from our gastroenterology department. Patients diagnosed with IBD who underwent systematic upper gastro-intestinal endoscopy (UGE) were included. Clinical, endoscopic, and histopathological data were gathered and analyzed. Results 141 CD and 61 UC patients were included. The mean age was 40,7 years, and the female to male ratio was 1,33. 95.5% of these patients had no upper gastrointestinal symptoms prior to undergoing UGE. Among the symptomatic participants, the most frequent complaints were dyspepsia and pyrosis. In 73.9% of asymptomatic patients, UGE showed a normal mucosa, the abnormalities found in these patients were: non-specific gastro-duodenal erosions and ulcerations (8.5% of cases), mild esophagitis (4% of cases), aphthoid ulcerations (2% of cases) and duodenal stenosis (0.5% of cases). In symptomatic participants, UGE was normal in 4 cases, it showed atrophy of the fundus mucosa in 1 case, esophageal hernia in 2 cases, and esophageal aphthoid ulcerations in 1 case. Gastro-duodenal biopsies were consistently undertaken, among asymptomatic patients, histopathological abnormalities included: lymphoplasmacytic Infiltrate (47,7%) and helicobacter pylori (HP)(38,1 %), nonspecific duodenitis (44,7%), gastric metaplasia, focal gastritis, atrophic villi and crypt hyperplasia were objectified in 3,5%, 3%, 1,5% and 0,5% of cases. Granulomas were noted in only 1% of cases, and Cryptitis and crypt abscess in 0,5%. In symptomatic participants, histologic abnormalities included metaplasia in the fundus (0.5%), lymphoplasmacytic infiltrate (2.5%), HP (2,4%), atrophic villi in the duodenum (0.5%) and glandular atrophy (0.5%). Our analysis did not reveal any significant associations between endoscopic lesions and UC (p=0.36) or CD (p=0.09) nor the presence of symptoms (p=0.08), however, a significant association was identified between male gender and the presence of endoscopic lesions (p=0.033). Conclusion Although IBD patients might be asymptomatic, UGE and histopathological examination may reveal upper gastrointestinal abnormalities and aid to a better assessment and management of IBD patients.

Upper gastrointestinal tract involvement of Crohn disease: clinical implications in children and adolescents.

Crohn disease (CD) is a multifactorial inflammatory disorder that can affect all segments of the gastrointestinal (GI) tract but typically involves the ileum and/or colon. To assess patient prognosis and choose appropriate treatment, it is necessary to accurately evaluate the factors influencing poor outcomes, including disease phenotype. Pediatric CD involving the upper GI (UGI) tract has become increasingly recognized with the introduction of routine upper endoscopy with biopsies for all patients and the increased availability of accurate small bowel evaluations. Most clinical manifestations are mild and nonspecific; however, UGI involvement should not be overlooked since it can cause serious complications. Although controversy persists about the definition of upper GI involvement, aphthoid ulcers, longitudinal ulcers, a bamboo joint-like appearance, stenosis, and fistula are endoscopic findings suggestive of CD. In addition, the primary histological findings, such as focally enhanced gastritis and noncaseating granulomas, are highly suggestive of CD. The association between UGI involvement and poor prognosis of CD remains controversial. However, the unstandardized definition and absence of a validated tool for evaluating disease severity complicate the objective assessment of UGI involvement in CD. Therefore, more prospective studies are needed to provide further insight into the standardized assessment of UGI involvement and long-term prognosis of CD. Our review summarizes the findings to date in the literature as well as UGI involvement in CD and its clinical implications.

Upper Gastrointestinal Tract Involvement in Inflammatory Bowel Diseases: Histologic Clues and Pitfalls.

The upper gastrointestinal (UGI) manifestations of inflammatory bowel diseases (IBDs) are frequently obscured by classic ileal and colonic symptoms and are reported to involve only 0.5% to 4% of adult patients. However, because of the improvement of endoscopic techniques and the growing use of esophagogastroduodenososcopy with biopsy, both asymptomatic and clinically significant esophageal, gastric, and duodenal manifestations are increasingly recognized. The UGI involvement in IBD was historically synonymous with Crohn’s disease (CD), but the doctrine of ulcerative colitis (UC) being limited to the colon has been challenged, and UC-related gastroduodenal lesions have been reported. The diagnosis of UGI IBD should ideally rely on a combination of the clinical history, endoscopic picture, and histologic features. Although endoscopic changes such as aphthoid or longitudinal ulcers and bamboo-joint-like pattern are suggestive of CD, histologic evaluation increases the sensitivity of the IBD diagnosis since histologic alterations may be present in endoscopically unremarkable mucosa. Conversely, in many cases, the histologic findings are nonspecific, and the knowledge of clinical history is vital for reaching an accurate diagnosis. The presence of epithelioid granuloma is highly suggestive of CD but is present in a minority of CD cases; thus, pathologists should be aware of how to diagnose UGI IBD in the absence of granulomata. This article reviews the most important clinical, endoscopic, and histologic features of IBD-associated esophagitis, gastritis, and duodenitis, as well as the IBD-related manifestations in the biliary tract and the postcolectomy setting.

P576 The value of small bowel capsule endoscopy in the change of therapeutic management in patients with established Crohn’s disease

Abstract Background Small bowel capsule endoscopy (SBCE) is widely used for various indications in patients with established Crohn’s disease (CD). Our aim was to investigate whether SBCE can lead to changes in the therapeutic management of CD patients. Methods Retrospective analysis of prospectively collected data [September 2003 - September 2019] from patients with established CD subjected to SBCE in two tertiary referral centres for inflammatory bowel diseases. All patients were tested with the Pillcam SB. Findings consistent with small bowel CD involvement were the presence of aphthoid or larger ulcers with or without inflammation of the adjacent mucosa. Results In total, 839 patients [median age (range) 36 (17–78) years, 471 (56.41%) men, median disease duration 6 years] diagnosed with CD according to established criteria underwent SBCE in the participating centres for the evaluation of disease extent and mucosal healing or the investigation of clinical relapse or iron deficiency anaemia. Based on ileo-colonoscopy findings disease location was documented in 618 patients (73.65%) as follows: colitis in 219 (26.10%), ileo-colitis in 253 (30.15%), and terminal ileitis in 146 (17.40%) patients; in contrast, full disease location was not documented in 221/839 (26.34%) patients who had colonic involvement but the ileocaecal valve could not be intubated. In the latter group, SBCE revealed small bowel involvement in 96 (43.43%) patients. In addition, SBCE revealed more proximal lesions in 105/618 (16.99%) patients with ileo-colonoscopy documented colitis, ileo-colitis or terminal ileitis. These findings led to a change in therapeutic management in 98 patients (11.68%): 36 patients (4.29%) received biologics, 21 patients (2.50%) received intensified doses of or changed the administered biologic, 39 patients (4.64%) received corticosteroids and/or conventional immunosuppressants and 2 patients (0.23%) underwent surgery. Therapeutic management changes were commoner in patients in whom small bowel lesions were found during SBCE and in whom the terminal ileum had not been examined during colonoscopy (57/96 patients vs. 41/105, p = 0.003]. Capsule retention occurred in 9 patients (1.07%) and passed after administration of corticosteroids (n = 6), or the capsule was retrieved with push enteroscopy (n = 1) or surgery (n = 1). Conclusion SBCE is a valuable tool in the management of patients with established CD, especially in those whom the terminal ileum has not been examined during the preceding colonoscopy.

Crohn's disease of esophagus, stomach and duodenum.

Crohn’s disease with involvement of the esophagus, stomach and duodenum has a prevalence of 0.5% to 4% in symptomatic adult patients, but some studies have shown that these results may be underestimated, since upper gastrointestinal endoscopy is not performed routinely in the initial evaluation of the disease in adult patients, as it is in the pediatric population. In general, involvement of the upper gastrointestinal tract in Crohn’s disease occurs concomitantly with involvement of the lower gastrointestinal tract. The diagnosis depends on clinical, endoscopic, histological and radiological evaluation. The presence of aphthoid ulcers, longitudinal ulcers, bamboo-joint-like appearance, stenoses and fistulas are endoscopic findings suggestive of the disease, and it is important to exclude the presence of Helicobacter pylori infection. The primary histological findings, which facilitate the diagnosis, are the presence of a chronic inflammatory process with a predominance of lymphoplasmacytic cells and active focal gastritis. The presence of epithelioid granuloma, although less frequent, is highly suggestive of the disease in the absence of chronic granulomatous disease. Treatment should include the use of proton pump inhibitors associated with corticosteroids, immunomodulators and biological therapy according to the severity of the disease.

Giant aphthae

Aphthae are single or multiple small painful ulcers, preceded by a burning sensation, with a yellow background surrounded by a non-indurated red border, healing usually in 8-10 days. They usually affect the buccal mucosa, but sometimes they are bipolar (orogenital) with possible variants: deep aphthae >1cm, herpetiform aphthae measuring 1-3mm, giants aphthae, miliary aphthae. Benign idiopathic aphtosis is frequent, reactivated by contact with some food (citrus fruit, tomato, walnuts, gruyère). Some drugs can cause aphthoid ulcerations: nonsteroidal anti-inflammatory drugs, nicorandil, alendronate sodium, betablockers, opiate analgesics, savarine, sirolimus, anti-EGFR. Complex aphtosis (at least 3 recurrent episodes of ulcers) can lead to enterocolopathy or celiac disease, sometimes revealing martial or vitamin deficiency (folates, vitamin B12). Bipolar aphtosis is strongly suggestive of Behçet's disease. We report the case of a 40-year old man presenting for increase in left thigh volume. Ultrasound showed aneurysm of the femoral artery. Clinical examination objectified giant aphthous ulcer in the tongue. Patient interview revealed recurrent genital and buccal aphthae and ophthalmologic examination showed posterior uveitis. The diagnosis of Behçet's disease was retained and emergency bolus dose of corticosteroids with immunosuppressants (cyclophosphamide) was started.

A Case of Very Early‐Onset Crohn's Disease Presenting With Intractable Stomatitis and Cheilitis as Its Major Signs

BackgroundOral inflammatory lesions assist in the diagnosis of certain systemic diseases that primarily affect other organs.MethodsA young girl, 3 years and 3 months old, presented with aphthous stomatitis, upper lip cheilitis, and swelling and bleeding of the upper gingiva. She had a medical history of repeated fever, skin tag of the anus, and constipation. Thus, it was suspected that her disease is a systemic disease with digestive symptoms. From clinical manifestation and endoscopy findings containing aphthoid ulcers in the bowel, she was diagnosed with very early‐onset Crohn's disease (CD). Immediately, mesalazine was started.ResultsAfter 1 month, the oral symptoms were dramatically improved, and her general condition stabilized.ConclusionsOral symptoms often precede the appearance of gastrointestinal lesions in young CD patients, and oral conditions worsen if the disease remains untreated. Thus, assessment of patients with intractable stomatitis from the viewpoint of CD may aid in rapid diagnosis and better prognosis.

Secondary Eosinophilic Colitis Obscuring the Diagnosis of Crohnʼs Disease

A 30 year-old male presented with a 3-month history of abdominal pain, nausea, vomiting, diarrhea, bleeding per rectum, and weight loss. He was hospitalized with similar symptoms at another facility 3 weeks ago where he was diagnosed to have ulcerative colitis based on colonoscopy and was treated with steroids. He had some improvement but after his medication ran out, his symptoms began to worsen. On admission, he had leukocytosis and stool Clostridium difficile toxin was positive while all other stool studies were negative. CT scan of the abdomen/pelvis showed inflammation in the terminal ileum and cecum. Colonoscopy revealed an ulcerated proliferative mass with multiple polyploid lesions nearly occluding the lumen in the proximal ascending colon and cecum, scattered aphthoid ulcers in the rectum and normal intervening colonic mucosa. Biopsy of the cecal lesion showed focal architectural distortion, acute and chronic inflammation with marked eosinophilic infiltration and absence of granulomas. Rectal biopsy showed mild inflammation and random biopsies of the intervening colon mucosa were normal. Patient was treated with oral metronidazole for 10 days without improvement in symptoms even though repeat stool C. diff toxin was negative. Mesalamine was started for presumed inflammatory bowel disease (IBD) resulting in minimal improvement. A CT enterography was then performed and showed severe bowel wall thickening and mucosal enhancement in the cecum, proximal ascending colon and terminal ileum, and a possible fistula tract between the cecum and ascending colon. Thereafter, IV methyl prednisolone was started with consequent rapid improvement in symptoms. He was then discharged home on a 2 month slow taper of prednisone and sulfasalazine. Eosinophilic colitis is a diagnosis of exclusion with a wide differential for the etiology. Although no granulomas were seen on the colon biopsies, the focal architectural distortion, colo-cecal fistula on imaging, and improvement with steroids suggested Crohn's disease over idiopathic eosinophilic colitis or ulcerative colitis. Incidentally, gASCA (anti-Saccharomyces cerevisiae antibody) levels were high (163 units), highly indicative of Crohn's disease over ulcerative colitis. The association between IBD and mucosal eosinophilia has been increasing, although the pathophysiology is unknown; but in a patient like ours the clinical suspicion for IBD, particularly Crohn's disease, must remain high.Figure 1Figure 2Figure 3

Dermatomyosite juvénile de survenue précoce et de présentation inhabituelle

A 13-month-old infant presented with an edema of the upper lip, 4days after receiving amoxicillin-clavulanate. The patient was treated with betamethasone and an antihistamine. Progression was marked by the appearance of a white edema of the periorbital area and the upper lip, with purpuric lesions, aphthoid ulcerations, and a drooping head. Very high muscle enzymes, a myogenic electromyogram, and hypertrophic cardiomyopathy were found and diagnosis of JDM was retained. The patient was treated with a high dose of corticosteroids and methotrexate. Before the installation of dysphagia, dysphonia, and axial hypotonia, the bolus of cyclophosphamide was administered, with clear improvement. Corticosteroids and methotrexate were then kept over the long term. The originality of this observation of JDM resides in the very young age of onset of the disease, its unusual cutaneous signs including labial edema extending to the regions around the eyes, its severe muscle manifestations causing axial hypotonia, and finally, in its association with hypertrophic cardiomyopathy. Early initiation of treatment (12 days after the onset of symptoms) greatly improved the prognosis of this form of JDM, which is very severe and refractory to first-line therapy.

Incidental De Novo Crohn’s Disease in the Elderly: A Case Series

Introduction: Crohn’s disease (IBD) is primarily a condition diagnosed in younger patients. In 10-15% of cases, patients are diagnosed over the age of 60. Studies have questioned whether elderly patients may present differently compared to younger patients. We report on 3 patients diagnosed with CD after the age of 65 to demonstrate how elderly patients may present differently and require different management considerations. Cases: Patient 1 is a 75-year-old male referred for evaluation of a small bowel polyp and associated anemia. Prior work-up included a negative upper endoscopy (EGD) and colonoscopy (COL), along with multiple video capsule endoscopy (VCE) studies. The last VCE confirmed the presence of a small bowel polyp. Re-review of the VCE demonstrated an inflammatory lesion seen in the mid-jejunum, a small inflammatory polyp in the mid-bowel, and multiple small ileal ulcers with intra-villus hemorrhages, all suggesting CD. Given that he was asymptomatic, he was managed as having indolent CD and was managed with dietary modification and iron supplementation. Patient 2 is a 67-year-old male who had intermittent diarrhea and constipation for over 20 years. A CT scan of his urinary tract reported a thickening in the terminal ileum. Later, the patient had a normal screening COL, during which the terminal ileum was not visualized. The patient was initially referred to our clinic for worsening diarrhea, dyspepsia, and abdominal pain. An EGD demonstrated a small gastric polyp. VCE demonstrated scattered aphthoid and small ulcers in the jejunum and ileum, along with ulceration and inflammation in the distal ileum consistent with CD. The patient was diagnosed with indolent CD with superimposed IBS. The patient’s IBS was treated with dietary modifications and the CD did not require therapy. Patient 3 is a 78-year-old female referred for anemia requiring transfusion. Previously, the patient had a VCE demonstrating a jejunal polyp. Review of the VCE demonstrated an inflammatory polyp along with distal ileal ulcers, suggestive of CD. Since the patient required transfusions, it was recommended that she start on budesonide and/or pentasa therapy. Discussion: In our case series, 2 patients were diagnosed with CD incidentally. Their initial management reflected this as they were managed with dietary modifications. The third patient had severe anemia as part of her diagnosis, and was managed with minimal medical therapy. As our population grows older, it is likely that the prevalence of elderly patients with CD will increase and it will become more important to understand how their presentations will differ and how their managements may reflect those differences. Disclosure - Dr. David Cave - consultant for Olympus Medical Systems.

Focally Enhanced Gastritis Used as a Histological Marker in Two Cases of Crohnʼs-like Disease

Purpose: Gastroduodenal involvement of Crohn's disease has not been well characterized and estimated to be about 4% in one UK series. Focally enhanced gastritis is common in Helicobacter pylori negative patients with known distal Crohn's disease regardless of presence of granulomas or mucosal lesions at endoscopy. Immunostaining from gastric biopsies may reveal distinctive pattern of accumulation of perifoveolar or periglandular inflammatory infiltrates (CD3/CD 68). This may alter treatment plans and improve outcome in patients with Crohn's-like disease with earlier medical intervention. Case 1: A 59-year-old woman with prior history of Hashimoto's thyroiditis presented with abdominal pain, iron deficiency anemia, vomiting and diarrhea for 1 year. Upper endoscopy showed antral ulcers; Helicobacter pylori and fasting gastrin were negative. She was treated with pantoprazole for presumed peptic ulcer disease. Still, she remained symptomatic. Focal perifoveolar infiltrates were seen on antral biopsies. IBD serology (Prometheus) was negative. Capsule endoscopy showed multiple aphthoid ulcers in long segments without stenosis (Lewis score 900). Erosions seen in transverse colon on colonoscopy in the absence of use of NSAIDs. There was no evidence of inflammatory on CT abdomen. CRP was 11.5. CDAI 283. She responded well to infliximab and achieved clinical remission (CDAI <150) with normalization of CRP. Endoscopy after induction showed reduction of ulcer load in stomach and small intestine. She remained in clinical remission after 1 year of treatment. Case 2: A 61-year-old man admitted for gastric outlet obstruction. Upper endoscopy showed diffuse ulcers in antrum and proximal duodenum with stenosis. Gastrin, H. pylori serology and quantiferon TB were negative. CT abdomen showed thickened second portion of duodenum; colonoscopy showed ileitis and colon was normal. IBD serology (Prometheus) was consistent with Crohn's disease. He responded to pantoprazole with improvement of duodenal ulcers and stenosis but at least one-third of the antrum showed persistent dimunitive ulcers. Focally enhanced gastritis was seen on antral biopsies. Patient remained symptomatic with poor nutritional status. Infliximab was started and patient has been doing well on therapy. Symptomatic gastroduodenal Crohn's disease may be wrongly diagnosed as peptic ulcer disease delaying appropriate medical treatment. Presence of focally enhanced gastritis may serve as a histological marker for Crohn's disease. Further clinical investigation in mucosal histological marker is warranted in the subset of H. pylori negative patients with dyspepsia/recurrent peptic ulcer disease whom may have underlying immune dysfunction and elevated anti TNF.

Adult-onset Still's disease preceding Crohn's disease

Concomitant diagnosis of Crohn's disease and juvenile or adult-onset idiopathic arthritis is rare. It is possible that both conditions share some genetic or immunological defects although sufficient data are lacking.We describe herein the first case of a patient with adult-onset Still's disease who was diagnosed on follow up with concomitant Crohn's disease.A 38-year-old man diagnosed with adult onset Still's disease from the age of 24 was admitted in our hospital because of bloody diarrhea. On admission physical examination was unremarkable and all routine laboratory tests were normal except of Hg at 11.3gr/dl, erythrocyte sedimentation rate at 27mm/h and C-reactive protein at 14mg/dl.Ileocolonoscopy revealed small aphthoid ulcers in the terminal ileum and capsule endoscopy revealed the source of bleeding and small aphthoid ulcers starting from the distal jejunum up to the terminal ileum. Terminal ileum biopsies were diagnostic of Crohn's disease and patient had started on therapy with mesalamine 2gr/day and azathioprine 2mg/kg and is currently on multidisciplinary follow up.We review all literature on co-existence of Crohn's disease with chronic idiopathic arthritis and we discuss the possible difficulties in diagnosis and therapy of those patients also in the view of the new biological agents.

Infliximab induced endophthalmitis in a patient of fistulizing Crohn’s disease

We report a patient with fistulizing Crohn’s disease who developed bacterial endophthalmitis following a single infusion of infliximab. A 26-year-old lady presented with recurrent bloody diarrhea and perianal discharge since 2 years. She had undergone incision and drainage for a perianal abscess 9 months ago with no improvement. She had also received prednisolone and 5-aminosalicylic acid with no benefit. When she presented to us, she had episodes of bloody diarrhea and persistent perianal symptoms. Examination revealed multiple abscesses in perianal area with extensive cellulitis, and edematous left labia majora. She had leucocytosis and hypoproteinemia; liver function tests, renal function tests, chest skiagram and barium meal follow through were unremarkable. Pus culture grew Streptococcus hemolyticus. Colonoscopy showed multiple perianal sinuses, congested and edematous anal canal with aphthoid ulcers, areas of frank ulceration and mucosal bridging in sigmoid, descending and transverse colon. Histopathology from perianal area showed granulomatous inflammation consistent with Crohn’s disease; colonic biopsies showed chronic inflammation. During drainage of perianal abscesses

Disseminated histoplasmosis: a rare cause of multiple ulcers in the gastrointestinal tract

Histoplasmosis is an invasive fungal infec-tion that commonly presents as a pulmo-nary disease. The development of the dis-seminated form depends on the host’simmunity and involves the gastrointesti-nal tract in 70%–90% of autopsy studies[1]. The colon may be involved in 59.6%,followed by the small bowel [1]. Polypoidlesions, ulcerations, strictures, and per-forations can be observed [2,3]. The con-comitant involvement of the upper andlower gastrointestinal tract has neverbeen described in vivo. Furthermore,there are few reports of histoplasmosisafterliver transplantation[4].Herewede-scribe a case of disseminated histoplas-mosis in a patient following liver trans-plantation manifesting as gastric, duode-nal, and colonic ulcers, a presentationthat has not been described previously.A 68-year-old woman presented at AlbertEinstein Hospital in May 2010 with ab-dominal pain. She had a liver transplanta-tion 1 year ago. A computed tomography(CT) scan revealed lymph nodes in theliver hilum. During the endoscopic evalu-ation (endoscopy and colonoscopy), wefound many small gastric, duodenal, andcolonic aphthoid ulcers (

Multiple ulcers in the small and large intestines occurred during tocilizumab therapy for rheumatoid arthritis

Tocilizumab is a monoclonal antibody against human interleukin-6 receptor which blocks the binding of interleukin-6 to its receptor. Tocilizumab is effective for the treatment of inflammatory disorders including rheumatoid arthritis. We report a case of multiple ulcers in the small and large intestines, which occurred during tocilizumab therapy. A 57-year-old woman started to use tocilizumab for rheumatoid arthritis. Three months later, she complained of hematochezia. Double-balloon endoscopy revealed multiple small aphthoid ulcers in the small and large intestines. One month after the woman had recovered, she was given tocilizumab again. The woman had hematochezia and abdominal pain again 2 weeks later. Colonoscopy revealed multiple round, discrete punched-out ulcers in the terminal ileum, and vast deep ulcers from the cecum to the descending colon. Bioptic histopathology and cultivation showed non-specific findings. Six weeks after discontinuation of tocilizumab, ulcers in the small and large intestine dramatically improved, leaving ulcer scars. This disease course and the results of examination made us strongly suspect that tocilizumab induced multiple ulcers in the small and large intestines. Interleukin-6 is a pleiotropic cytokine and involved in intestinal mucosal wound healing as well as in inflammatory processes. It is possible that tocilizumab inhibited tissue repair of the intestine and caused intestinal ulcers.

MR Enterographic Manifestations of Small Bowel Crohn Disease

Magnetic resonance (MR) enterography is a clinically useful technique for the evaluation of both intraluminal and extraluminal small bowel disease, particularly in younger patients with Crohn disease. MR enterography offers the advantages of multiplanar capability and lack of ionizing radiation. It allows evaluation of bowel wall contrast enhancement, wall thickening, and edema, findings useful for the assessment of Crohn disease activity. MR enterography can also depict other pathologic findings such as lymphadenopathy, fistula and sinus formation, abscesses, and abnormal fold patterns. Even subtle disease manifestations may be detected when adequate distention of the small bowel is achieved, although endoscopic and double-contrast barium small bowel techniques remain superior in the depiction of changes in early Crohn disease (eg, aphthoid ulceration). Further research will be needed to determine whether MR imaging enhancement patterns may reliably help discriminate between active and inactive disease.

Wireless capsule endoscopy and proximal small bowel lesions in Crohn’s disease

To investigate the prevalence of proximal small bowel (SB) lesions detected by wireless capsule endoscopy (WCE) in Crohn's disease (CD). WCE was performed in 64 patients: 32 with CD of the distal ileum, and 32 controls with iron-deficiency anemia (IDA) or diarrhea. WCE was performed using the Given SB-WCE, followed by small intestine contrast ultrasonography (SICUS). Findings compatible with CD by using WCE included erosions, aphthoid or deep ulcers, and strictures/stenosis. WCE detected proximal SB lesions in 16/32 (50%) patients (14 aphthoid ulcers, 2 deep ulcers, one stricture), which appeared not to be related to clinical parameters [epigastric pain, age, smoking, non-steroidal anti-inflammatory drugs (NSAIDs), IDA]. Among patients with proximal SB lesions, 6 (37%) were smokers, 3 (19%) NSAID users, 3 (19%) had epigastric pain and 4 (25%) had IDA. SICUS detected proximal SB lesions in 3/32 patients (19%) also showing lesions with WCE. No correlations were observed between proximal SB lesions assessed by WCE or by SICUS (chi(2) = 1.5, P = 0.2). The use of WCE allows the detection of previously unknown upper SB lesions in a high proportion of patients with a previous diagnosis of CD involving the distal ileum.

Review: Advances in the diagnosis and treatment of small bowel lesions with Crohn’s disease using double-balloon endoscopy

With the recent development of double-balloon endoscopy (DBE) and capsule endoscopy (CE), it has become possible to observe the entire small bowel endoscopically. DBE enables us to make detailed observations and at the same time takes biopsy samples. Single-balloon endoscopy (SBE), which has a balloon only at the tip of the overtube, has also been introduced. Since DBE and SBE are similar in the concept of insertion method, a general term 'balloon-assisted endoscopy' (BAE) is used when referring to these methods. Characteristic small bowel lesions observed with BAE in Crohn's disease are aphthoid ulcers, round ulcers, irregular ulcers and longitudinal ulcers. These ulcers tend to be located on the mesenteric side of the small bowel. Since BAE can determine the location (mesenteric or antimesenteric side) of the ulceration, it is useful in distinguishing Crohn's disease from other diseases that have ulcers in the small bowel. Strictures are a major clinical problem in the course of Crohn's disease. Traditionally, surgery was the main choice for small bowel strictures. In some cases, strictures located in distal ileum or proximal jejunum have been dilated using standard enteroscopes. DBE now enables balloon dilatation to be performed endoscopically even in the deep small bowel.

Colite por citomegalovirus em paciente transplantada renal: relato de caso e revisão da literatura

A infecção do citomegalovírus ocorre geralmente em pacientes imunocomprometidos sejam pós-transplantados ou pelas doenças que comprometem o sistema imune (AIDS); apresentamos um caso de um paciente do sexo feminino de 49 anos de idade, que se encontrava em pós-operatório tardio de transplante renal (14 anos), fazendo uso de medicações imunossupressoras. Evolui com quadro de dor abdominal, perda do peso e diarréia não sanguinolenta na fase inicial, necessitando de hospitalização, durante a qual desenvolveu severos quadros de hematoquezia e hipotensão. Submetida a colonoscopia que revelou mucosa de aspecto friável, com úlceras do tipo aftóides, fibrina e formação de pseudopólipos; a biopsia revelou tratar-se de citomegalovírus. Evolui sem melhora com o uso do foscarnet r, necessitando de tratamento cirúrgico, indo a óbito após 5 dias.

Gastrointestinal Involvement in Pediatric Polyarteritis Nodosa

Gastrointestinal Involvement in Pediatric Polyarteritis Nodosa