Fluid-filled Small Bowel Loops Research Articles

S2738 Isolated Celiac Artery Vasculitis Presenting as Ileus in a Patient With Ulcerative Colitis

Introduction: Small case series have reported an association between IBD and large vessel vasculitides, ANCA-associated vasculitis, and cutaneous vasculitis. Gastrointestinal (GI) involvement of vasculitis can be a severe complication, resulting in mesenteric ischemia, ileus, or GI bleeding, and often requires aggressive medical or surgical interventions. We report a case of celiac artery vasculitis presenting as abdominal pain and ileus in a patient with ulcerative colitis (UC). Case Description/Methods: A 69 year old male with an 11 year history of UC in remission on infliximab and azathioprine (AZA) presented to the emergency room with abdominal pain and constipation for five days. He had decreased AZA from 200 mg to 100 mg one month prior. Initial CT abdomen and pelvis showed stranding surrounding the celiac artery, fluid-filled small bowel loops, and segmental areas of distal colon collapse with proximal colon distention. He developed progressive small bowel and colonic distention with cecum diameter of 10 cm. A colonoscopy was performed for decompression. He had no evidence of active UC. EGD demonstrated dusky appearing gastroesophageal junction and inflammation with cratered ulcers in the gastric cardia and body. Biopsies confirmed ischemic necrosis. CTA demonstrated perivascular inflammation of a patent celiac artery without evidence for dissection, suggestive of acute vasculitis. ESR and CRP were 50 mm/hr and 7.8 mg/dL respectively. Myeloperoxidase, serine-proteinase 3, rheumatoid factor, ANA, were negative. He was started on methylprednisolone IV with oral prednisone taper at discharge, and AZA was increased to 200 mg daily. A CT one month later showed minimal residual inflammation. ESR and CRP had normalized. (Figure) Discussion: We present the first case of isolated celiac artery vasculitis in a patient with IBD. A diagnosis of IBD often precedes vasculitis, and patients are typically on immunosuppressive therapy at the time of onset. Anti-TNF agents have been implicated as a potential inciting cause. Although it is unclear whether long-term anti-TNF therapy precipitated vasculitis in our patient, the dose reduction in AZA prior to presentation may have unmasked vasculitis. This was supported by his rapid clinical and radiographic improvement with combination of steroids and increased AZA dose despite continuation of infliximab. This case highlights the importance of maintaining a high degree of suspicion for vasculitis in patients with IBD on immunosuppressive therapy presenting with ischemia or ileus.Figure 1.: A 69 year old male underwent EGD for evaluation of abdominal pain and NG tube placement; he was found to have inflammation with a dusky appearing mucosa at the gastroesophageal junction (GEJ) (A). Non-bleeding gastric ulcers with overlying pigment (Forrest Class IIc) were identified (B). H&E stain image shows the GEJ biopsy with extensive ischemic necrosis and hemorrhage (C). Initial CTA abdomen/pelvis shows fat stranding surrounding the celiac artery (D).

P0756 / #2111: ABDOMINAL IMAGING FINDINGS IN CRITICALLY ILL CHILDREN WITH MIS-C

Aims & Objectives: We sought to describe abdominal imaging findings on ultrasound and computed tomography on children presenting with abdominal symptoms and multisystem inflammatory syndrome (MIS-C) related to coronavirus disease (COVID-19). Methods: We report findings on abdominal imaging in 7 critically ill children admitted with MIS-C to a tertiary, urban intensive care unit. All children had clinical and laboratory criteria of MIS-C including positive antibody testing to COVID-19. Results: Of 23 children diagnosed with MIS-C, 7 children (30%) had abdominal imaging, including ultrasound (all 7) and CT (3/7). Indications for abdominal imaging included concern for acute abdomen, gall bladder inflammation and intestinal obstruction. Hepatomegaly was the most common finding, while nephromegaly, gall bladder wall edema, ascites, intestinal inflammation and mesenteric lymphadenopathy were also seen on ultrasound. Two children had incidental finding of bilateral lower lobe consolidations on CT abdomen. One child had a thickened, enlarged appendix with diffuse inflammation of intestinal wall of descending colon and ileum on CT. Another patient with severe MIS-C had fluid-filled small bowel loops, terminal ileal inflammation, diffuse lymphadenopathy and moderate ascites on abdominal CT. This patient also had large vessel vasculitis involving the junction of the aortic arch and brachiocephalic trunk. Conclusions: Common with abdominal imaging findings in Kawasaki disease, our patients had reactive lymphadenopathy, abdominal free fluid, bowel wall thickening and vasculitis. Gall bladder hydrops, intestinal pseudo-obstruction or dilated bowel loops, commonly found in Kawasaki disease with prominent abdominal symptoms were not seen in our patients.

Abdominal Imaging Findings in Critically Ill Children With Multisystem Inflammatory Syndrome Associated With COVID-19.

We report findings on abdominal imaging in critically ill children admitted with MIS-C. On sonography, hepatomegaly, nephromegaly, gallbladder wall edema, ascites, intestinal inflammation and mesenteric lymphadenopathy were seen, while CT showed fluid-filled small bowel loops, mural thickening of the terminal ileum, diffuse lymphadenopathy, and moderate ascites.

An activating gucy2c mutation causes impaired contractility and fluid stagnation in the small bowel

Objective: Familial GUCY2C diarrhoea syndrome (FGDS) is caused by an activating mutation in the GUCY2C gene encoding the receptor guanylate cyclase C in enterocytes. Activation leads to increased secretion of fluid into the intestinal lumen. Twenty percent of the patients have increased risk of Crohn’s disease and intestinal obstruction (CD, 20%) and the condition resembles irritable bowel syndrome with diarrhoea. We aimed to describe fluid content, contractility, peristaltic activity and bowel wall thickness in the intestine in fasting FGDS patients, using ultrasound, with healthy volunteers serving as controls.Methods: Twenty-three patients with FGDS and 22 healthy controls (HC) were examined with a Logiq E9 scanner in a fasting state. Bowel wall thickness was measured and fluid-filled small bowel loops were counted using three-dimensional (3D) magnetic positioning navigation. The HC ingested 500 ml PEG solution, an electrolyte balanced, non-absorbable solution, in order to investigate the contractions of the small bowel.Results: The fasting 23 FGDS patients had significantly higher number of fluid-filled small bowel segments compared to 22 fasting HC, p < 0.001. A high number of non-occlusive contractions in the ileum was observed, which was significant when compared to HC after ingesting PEG solution, p < 0.016. An increase in intestinal wall thickness or other signs of CD were not observed.Conclusions: FGDS is characterised by multiple, fluid-filled small bowel loops with incomplete contractions and fluid stagnation in fasting state. These findings may play a role in the increased risk of bowel obstruction as well as IBS-like symptoms observed in these patients.

CT findings of small bowel strangulation: the importance of contrast enhancement

The purpose of this study is to illustrate computed tomography (CT) findings suggestive of small bowel strangulation. We have performed the precontrast and postcontrast CT with single and multidetector CT scanners and evaluated the bowel wall changes and mesentery changes and correlated them with the operative findings. The direct CT findings suggestive of small bowel strangulation included high-density bowel wall on precontrast scans; lack of, or diminished contrast enhancement of the involved bowel wall; localized mesenteric fluid accumulation (mesenteric congestion); and localized pneumatosis. The indirect CT signs included C- or U-shaped loops with mesenteric vessels converging toward the obstruction site, ascites, target sign, two adjacent collapsed round loops, and whirl sign. We particularly emphasize the importance of contrast enhancement of bowel mucosa for early diagnosis to differentiate strangulation from a mechanical obstruction without bowel ischemia, and also the importance to differentiate proximal secondary gas-filled dilated small bowel loops from distal primary involved fluid-filled small bowel loops because these two types of small bowel loops are present in the single peritoneal cavity. As early recognition of small bowel strangulation may help improve the patient outcome because the involved bowel loops can be preserved without resection, it is essential to become familiar with the CT signs suggested small bowel obstruction strangulation.