Mucosal Hyperenhancement Research Articles

Exploring the Use of Computed Tomography Enterography in the Evaluation of Small Bowel Disease: A Prospective Study.

Background A major development in noninvasive imaging modalities, computed tomographic enterography (CTE) has a number of benefits over conventional computed tomography (CT) and capsule endoscopy. Through the utilization of multidetector computed tomography (MDCT) technology, CTE expedites the assessment of small bowel diseases, especially in those segments that are not accessible through traditional endoscopy. This study's main goal is to thoroughly evaluate CTE's diagnostic accuracy for a range of small intestinal conditions. Methodology In this investigation, which is a prospective observational study, 40 patients, 25 men and 15 women, with suspected small intestinal disorders and ages ranging from 10 to 70 underwent CTE. To evaluate diagnosis accuracy, a combination of clinical symptoms, imaging data, and histopathological/ultrasonography findings were evaluated. Throughout the research procedure, ethical issues and statistical analysis were incorporated to guarantee validity and adherence to ethical norms. Results The most frequent findings on CTE were bowel thickening and mucosal hyperenhancement, which were seen in 25 (62.5%) and 20 (50%) of the patients, respectively. The majority of patients (65%) exhibited both the ileal and jejunal loops to be adequately distended in grade III. In 35% of the patients, grade II distensibility of the ileal and jejunal loops was seen. Conclusion When it comes to accurately detecting small intestinal disorders, CTE is superior. It evaluates extraintestinal, mural, and intraluminal diseases with efficacy, particularly in places that are difficult to reach. It is essential for directing clinical decisions because of its capacity to assess disease activity prior to endoscopy and see consequences.

Challenges and predictive radiological findings in the diagnosis of neuroendocrine tumors in patients with acute appendicitis.

Acute appendicitis is one of the most common surgical emergencies. With antibiotic-first treatment strategies gaining importance, the risk of an appendiceal tumor as an incidental finding or as the cause of appendicitis presents an obstacle to a conservative approach. Neuroendocrine tumors, the most frequent type of appendiceal tumors, are difficult to diagnose preopera-tively due to their small size. This study aims to identify predictive factors for neuroendocrine tumors in patients undergoing surgery for acute appendicitis by analyzing imaging and clinical characteristics, thereby enhancing preoperative diagnostic accuracy and guiding surgical interventions. This retrospective observational study included 1,298 patients who underwent appendectomy from January 2014 to May 2024. After excluding 59 patients with normal pathology results, 40 with variable pathologies, and 49 with inaccessible computed tomography (CT) images, 1,150 patients remained (1,135 with acute appendicitis and 15 with neuroendocrine tumors). Abdominal CT scans were evaluated for appendiceal diameter, wall thickness, cecal wall thickness, periappendiceal fat stranding, fluid collection, lymphadenopathy, intraluminal and free periappendiceal air, mucosal hyperenhancement, the presence of appendicolith, mural calcification, and mural nodules. The presence of a mural nodule protruding into the lumen was significantly higher in neuroendocrine tumor patients compared to those with acute appendicitis, with a sensitivity of 53.3%, specificity of 95.8%, positive predictive value (PPV) of 31.9%, negative predictive value (NPV) of 99.4%, and accuracy of 97.9%. Intraluminal air was also more frequent in neuroendocrine tumor patients, with a sensitivity of 53.3%, specificity of 76.7%, PPV of 2.9%, NPV of 99.2%, and accuracy of 76.4%. Other imaging parameters did not show significant differences between the two groups. This study identifies mural nodules and intraluminal air as significant predictors of neuroendocrine tumors in patients with acute appendicitis, emphasizing the importance of meticulous preoperative imaging evaluations. Incorporating these predictors into diagnostic protocols could improve the preoperative identification of neuroendocrine tumors, enabling more appropriate surgical interventions. Future research should validate these findings through prospective studies and explore advanced imaging techniques to further enhance the detection of appendiceal neoplasms, ultimately improving patient outcomes and reducing overlooked malignancies.

Comparative study of imaging features in uncomplicated and complicated acute appendicitis.

Acute appendicitis is a common cause of acute abdominal pain necessitating surgical intervention. While the traditional treatment has been urgent appendectomy, recent studies suggest that an antibiotics-first approach can be safe for uncomplicated cases. Classifying appendicitis into uncomplicated and complicated categories is crucial for guiding treatment decisions and predicting patient outcomes. This study aims to evaluate the distinct imaging findings associated with uncomplicated appendicitis and its complicated subtypes-phlegmonous, gangrenous, and perforated appendicitis-to aid in differential diagnosis. This retrospective observational study was conducted from January 2014 to December 2023 and included 1,250 patients (492 women, 758 men) who underwent an appendectomy with available pathology results. After excluding 56 patients with normal pathology, 52 with non-appendicitis pathologies, and 48 with inaccessible computed tomography (CT) images, 1,094 patients were analyzed. CT images were evaluated for appendiceal diameter, wall thickness, cecal wall thickness, periappendiceal fat stranding, effusion, lymphadenopathy, intraluminal and free periappendiceal air, mucosal hyperenhancement, and the presence of appendicolith. The diameter of the appendix, along with the presence of periappendiceal air, effusion, and intraluminal appendicolith, were significantly higher in the perforated appendicitis group compared to other groups (p<0.05). Periappendiceal fat stranding, evaluated as a binary variable, did not show significant differences among the groups. Appendiceal wall thickness was higher in the perforated group and lower in the non-perforated gangrenous group compared to the uncomplicated group (p<0.05). No significant correlation was found for mucosal hyperenhancement between the appendicitis subgroups. Intraluminal air, though normal in a healthy appendix, was a specific predictor of complicated appendicitis when combined with other findings. This study provides a detailed analysis of distinct imaging findings associated with uncomplicated and complicated appendicitis. Key differentiators such as appendiceal diameter, periappendiceal air, effusion, and intraluminal appendicolith are crucial for accurate diagnosis. The findings highlight the importance of these parameters in distinguishing various types of appendicitis, offering valuable insights for clinical practice. Future prospective studies and advanced imaging techniques are needed to validate these findings and enhance the diagnosis and management of acute appendicitis and its complications.

Appendiceal wall thickness and Alvarado score are predictive of acute appendicitis in the patients with equivocal computed tomography findings

Around 8–13% of the patients who underwent CT scan for diagnosis of appendicitis had equivocal CT results. About one-third of these patients had acute appendicitis and this caused diagnostic challenge to the clinicians. This study was conducted to identify clinical and imaging features that were predictive of acute appendicitis in patients who had equivocal CT findings. During January 2015 to June 2021, we retrospectively included 103 consecutive CT scans of adult patients (22 men and 81 women; mean age, 39.1 ± 17.5 years) who had equivocal CT findings of acute appendicitis. Two readers, blinded to the clinical data, independently assessed CT images for the relevant CT findings of appendicitis. Any disagreement between the readers was solved by consensus. The clinical parameters and CT findings were analyzed and compared between the patients who had appendicitis and patients who did not have appendicitis. Thirty-one (30.1%) patients had appendicitis, all of which were non-complicated. The appendiceal wall thickness of ≥ 2 mm and the Alvarado score of ≥ 7 were independent predictors of appendicitis with adjusted odds ratios (ORs) of 2.76 (95% CI, 1.09–7.02) and 1.47 (95% CI, 1.12–1.94), respectively. The maximal appendiceal diameter was higher in the appendicitis group (7.2 ± 1.2 mm vs. 6.5 ± 1.0 mm), but not predictive of appendicitis. The rest of the clinical parameters and CT findings, including mucosal hyperenhancement, periappendiceal fat reticulation, thickening of peritoneal reflection, appendicolith, focal cecal thickening, and content in appendiceal lumen showed no significant difference between two groups. The appendiceal wall thickness and the Alvarado score were able to predict appendicitis in patients who had equivocal CT findings.

Role of computed tomographic enterography for evaluation of small bowel diseases: A cross-sectional study

Background: Computed tomographic enterography (CTE) is a newer non-invasive modality having distinct advantages over conventional CT and capsule endoscopy. Objectives: This technique allows faster evaluation of small bowel diseases in the endoscopically inaccessible segments. Being an operator-independent procedure, CTE is widely available and allows a better depiction of extra enteric complications. The aim is to evaluate CTE features of various small bowel diseases and the role of 2% mannitol for adequate small bowel distension. Materials and methods: A cross-sectional study comprising 105 patients had presented with small bowel diseases. Patients in the age group of 10 to 85 years with complaints of fever, abdominal pain, nausea, vomiting, altered bowel habits, loss of appetite and loss of weight were included in this study. CTE images were analyzed to compare the diagnosis with the available histopathological and ultrasonography results. Results: Among the study population, the majority had presented CTE features such as symmetrical wall thickening (53.3%), peri-bowel inflammatory changes (61%), mucosal hyperenhancement (39%), and mural stratification, i.e., target sign (33.3%). The majority of diagnoses of CTE were ileocecal tuberculosis (11.5%), small bowel inflammation (7.6%), and Crohn’s disease (6.7%). Other conditions such as small bowel neoplastic masses, diverticula, ischemic bowel disease, bowel strictures, intussusception, and ulcerative colitis. Conclusion: CTE has the vital role of first-line modality in the work-up of suspected small intestinal diseases and helps evaluate disease activity before endoscopy, particularly in inaccessible segments. It allows a better depiction of extra enteric complications of the bowel.

Reperfusion injury on computed tomography following endovascular revascularization of acute mesenteric ischemia: prevalence, risk factors, and patient outcome

BackgroundData about reperfusion injury (RI) following acute arterial mesenteric ischemia (AAMI) in humans are scarce. We aimed to assess the prevalence and risk factors of RI following endovascular revascularization of AMI and evaluate its impact on patient outcomes.MethodsPatients with AAMI who underwent endovascular revascularization (2016–2021) were included in this retrospective cohort. CT performed < 7 days after treatment was reviewed to identify features of RI (bowel wall hypoattenuation, mucosal hyperenhancement). Clinical, laboratory, imaging, and treatments were compared between RI and non-RI patients to identify factors associated with RI. Resection rate and survival were also compared.ResultsFifty patients (23 men, median 72-yrs [IQR 60–77]) were included, and 22 were diagnosed with RI (44%) after a median 28 h (22–48). Bowel wall hypoattenuation and mucosal hyperenhancement were found in 95% and 91% of patients with post-interventional RI, respectively. Patients with RI had a greater increase of CRP levels after endovascular treatment (p = 0.01). On multivariate analysis, a decreased bowel wall enhancement on baseline CT (HR = 8.2), an embolic cause (HR = 7.4), complete SMA occlusion (HR = 7.0), and higher serum lactate levels (HR = 1.4) were associated with RI. The three-month survival rate was 78%, with no difference between subgroups (p = 0.99). However, the resection rate was higher in patients with RI (32% versus 7%; p = 0.03).ConclusionRI is frequent after endovascular revascularization of AAMI, especially in patients who present with decreased bowel wall enhancement on pre-treatment CT, an embolic cause, and a complete occlusion of the SMA. However, its occurrence does not seem to negatively impact short-term survival.

S55 Pouch Enteroliths Resulting in Stercoral Hemorrhage: An Extremely Rare Complication of a Chronic Rectal Cuff Stricture in an Ileoanal Pouch

Case: Background: Enterolithiasis in the bowel is a rare condition. Less than 30 cases of enterolithiasis in Crohn's disease patients have been reported. Within the medical literature, a single case of pouch enteroliths has been reported. Herein, we described an extremely rare case of a patient with pouch stricture and enteroliths. Case: A 65-year-old male with morbid obesity, coronary artery disease, and a history of pulmonary embolism presented to the outpatient office endorsing 15-18 non-bloody liquid bowel movements daily, abdominal pain and cramping for 2 months. He denied nausea, vomiting, weight loss. He has a history of presumed ulcerative colitis s/p IPAA in 1988 and his diagnosis transitioned to Crohn’s disease for known pouch-anal anastomotic stricture requiring serial dilations for the past twenty years. He was on no biologics. His last pouchoscopy was performed 12 months prior and revealed stricture at the anus and stricture at the pouch inlet without pouchitis. Of note, several months prior to being seen he had a lower GI hemorrhage from the cuff requiring several transfusions. During his office visit, findings were notable for severe stenosis of the anal canal on digital rectal exam. CT enterography demonstrated a stricture at the pouch inlet with active inflammation, mild mucosal hyperenhancement of the lower pouch extending into the anus concerning for pouchitis, and perianal soft tissue stranding without discrete fistula tract identified. He was taken to the operating room for a pouchoscopy which identified a long 5 cm rectal cuff which was strictured and dilated. Upon dilation, a large amount of liquid stool was lavaged endoscopically to decompress the pouch; after further lavage, half a dozen large enteroliths with sharp edges were removed with a Roth net, snare, and ring forceps. Further pouch intubation was performed to the inlet stricture, which was endoscopically passable. Strictures were both biopsied and revealed chronic active enteritis with ulceration and pyloric gland metaplasia, negative for granulomas or dysplasia. In the follow-up, the patient was started a 3-month taper of budesonide with plan to restart biologics in the future if a response was seen on endoscopy. Pouchoscopy was repeated one week after budesonide was started; the procedure revealed worsening inflammation of the afferent limb. No enteroliths were found. Patient is planned for further surgical discussion and staged intervention with diverting ileostomy, leading to possible pouch excision in the future. Discussion: Strictures will form in up to 40% in patients with Crohn’s disease and may lead to obstructive symptoms, but also fecal stasis - the most important factor in the development of enteroliths. Studies have shown that enterolithiasis in Crohn’s disease occurs only in patients with a long history of mainly untreated symptoms of between 7 and 40 years. Thus, it is critical that rectal cuff strictures be managed surgical to avoid complications by experts, for patients to keep up with endoscopic surveillance, as well as referral to a colorectal surgeon for further management of the strictures to avoid the development of this uncommon complication.

OA19 A case of severe refractory lupus enteritis and nephritis that remitted with Obinutuzumab

Introduction/BackgroundSystemic lupus erythematosus (SLE) is an autoimmune disease that can affect almost any organ system but gastrointestinal (GI) involvement is very rare. Obinutuzumab is a humanised type II anti-CD20 monoclonal antibody that is licensed to treat haematological malignancies. It has been used in a small number of SLE patients with secondary non-depletion non-response (2NDNR) to Rituximab and appears to be effective in lupus nephritis (LN) as outlined in the NOBILITY trial. We present a case of refractory lupus enteritis (LEn) and LN in a patient with 2NDNR to repeated Rituximab cycles that achieved remission with Obinutuzumab.Description/MethodA 19-year-old African woman was diagnosed with SLE in 2018 after presenting with polyarthritis without systemic involvement. Blood tests showed leucopenia, positive antinuclear antibody, anti-double-stranded DNA >200 IU/ml and hypocomplementaemia. Prednisolone and Methotrexate were commenced. However, one month later she presented to hospital with generalised abdominal pain, vomiting and diarrhoea. CT abdomen demonstrated significant small bowel wall thickening with mucosal hyperenhancement. Multidisciplinary team (MDT) input confirmed likely LEn. She was treated successfully with intravenous Methylprednisolone and Rituximab. Total parenteral nutrition was required for two weeks.Unfortunately, four further hospital admissions followed over the next six months due to GI symptoms, transient acute kidney injury and moderate proteinuria. Small bowel oedema persisted on MRI, three months after the CT. Renal biopsy demonstrated class 2 LN. Intravenous methylprednisolone helped and further Rituximab was given but she had infusion reactions. Six months later she re-presented with abdominal pain, synovitis and had nephrotic range proteinuria. She was treated again for LEn after gastroenterology input. Further Rituximab was given (MabThera instead of Truxima) but reactions still occurred and her B cells were non-deplete. Repeat renal biopsy confirmed class 4 LN and intravenous Cyclophosphamide (Euro-Lupus regimen) was commenced. This was repeated seven months later due to persisting high disease activity and proteinuria despite a short trial of intravenous Belimumab. However, she was admitted to hospital with colitis on CT after completing the second course of Cyclophosphamide. MDT decision was to treat with Obinutuzumab. Since commencing treatment eighteen months ago, her SLE has dramatically improved and she feels well for the first time. SLEDAI-2K score is 2 (16 pre-treatment), renal function has recovered with mild proteinuria. Anti-double-stranded DNA has reduced from >200 to 52.9 IU/ml and complements normalised. She remains on Prednisolone 5mg daily and Tacrolimus and a third maintenance dose of Obinutuzumab is planned.Discussion/ResultsLEn has been reported in only 0.2-5.8% of SLE cases. It is defined by the British Isles Lupus Assessment Group (BILAG 2004) by either vasculitis or inflammation of the small bowel supported by imaging or histology. Its pathogenesis is poorly understood but thought to be related to immune complex deposition and complement activation resulting in intestinal capillary leak and submucosal oedema. Symptoms are non-specific and a review by Janssens et al. (2013) suggested abdominal pain (97%), ascites (78%), nausea (49%), vomiting (42%) and diarrhoea (32%) were the most common symptoms in patients with LEn. They reported the ileum and jejunum were most commonly affected in LE (84% and 83% respectively), followed by colon (19%), duodenum (17%) and rectum (4%).Abdominal CT is considered to be the first line investigation and ‘classic’ radiological findings are bowel wall oedema (“target sign”), engorgement/increased number of mesenteric vessels (“comb sign”) and increased attenuation of the mesenteric fat (Ha et al. 2000, and Kim et al. 2006). These were all demonstrated on our patient’s initial CT abdomen which showed engorgement of the mesenteric vessels from the proximal jejunum to the proximal ileum.LEn seldom occurs in isolation and usually presents in the context of high disease activity and other systemic involvement. It is often responsive to glucocorticoids and bowel rest but further immunosuppression with Cyclophosphamide or Rituximab might be warranted in refractory cases as in our patient’s case.Obinutuzumab has been shown to be safe, effective and steroid-sparing in renal and non-renal SLE patients with 2NDNR to Rituximab from a case series of 9 patients by Arnold et al. (2022). This applied to LN in our patient and we believe this to be the first case where refractory LEn was treated successfully with Obinutuzumab.Key learning points/ConclusionAlthough very rare, have a high index of suspicion of LEn in SLE patients who present with GI symptoms and typical radiological findings.LEn often occurs with other systemic manifestations including LN and it is important to assess for these at the time of diagnosis of LEn.Obinutuzumab is an emerging treatment for severe SLE particularly 2NDNR to Rituximab and can improve both LN and LEn. We eagerly await results from the current REGENCY and ALLEGORY clinical trials which are assessing Obinutuzumab in renal and non-renal SLE patients respectively.

Abnormal findings on abdominopelvic cross-sectional imaging in patients with microscopic colitis: a retrospective, multicenter study

Objectives Patients with microscopic colitis may have subtle macroscopic findings on colonoscopy such as erythema, edema, or altered vascular pattern; however, radiographic abnormalities on cross-sectional imaging have not been investigated. We aimed at identifying the abdominopelvic radiographic abnormalities in patients with microscopic colitis, as well as possible correlation with endoscopic findings and the need for extended duration of treatment. Materials and Methods This was a retrospective study of patients with biopsy-proven microscopic colitis at two tertiary centers between 1 January 2010 and 30 April 2020. Patients underwent computed tomography scan or magnetic resonance imaging within 30 days of a diagnostic flexible sigmoidoscopy or colonoscopy. Patients with colon ischemia and other causes of colitis were excluded. Radiographic abnormalities from imaging reports included bowel wall thickening, mucosal hyperenhancement and mesenteric fat stranding. Univariate and multivariable logistic regression models were used to identify predictors of radiographic abnormalities. Results 498 patients with microscopic colitis underwent abdominopelvic cross-sectional imaging within 30 days of flexible sigmoidoscopy/colonoscopy. Lymphocytic colitis was diagnosed in 54.6% of patients, and collagenous colitis in 45.4%. Endoscopic and radiographic abnormalities were identified in 16.1% and 12.4% of patients, respectively. Radiographic abnormalities were associated with the need for budesonide therapy (p = .029) and budesonide therapy long-term (p = .0028). Budesonide therapy long-term (p = .047) was associated with radiographic abnormalities in multivariate analysis. Conclusions Radiographic abnormalities may be present on abdominopelvic cross-sectional imaging in a minority of patients with biopsy-proven microscopic colitis, suggesting cross-sectional imaging has low clinical value in the evaluation and treatment of this disease.

S2431 Ulcerative Colitis Flare-Ups Following mRNA COVID-19 Vaccination

Introduction: Ulcerative colitis (UC) is an autoimmune disease commonly managed with immunosuppressants. However, its put UC patients at a higher risk for infections. Therefore, vaccination is an important part of management. Messenger RNA (mRNA) vaccine is a new type of vaccine only widely used against COVID-19. The effect of mRNA vaccines on UC patients on immunomodulatory treatement is relatively unknown. Here, we present the first case of UC flare-up after receiving the SARS-CoV-2 mRNA vaccine. Case description/methods: A 36-year-old female with past medical history of ulcerative colitis, autoimmune pancreatitis presented with intermittent lower abdominal pain and diarrhea for 2 weeks with fever for 1 day. Her last flare-up was 3 years ago before she was put on Tofacitinib. She never required hospitalization. Her symptoms started the second day after she received the second dose of Pfizer COVID-19 vaccine. She had daily 5-10 times of non-bloody diarrhea and abdominal cramps. Her symptoms subsided after 7 days of initial onset. On day 11, she started to have daily up to 15 times bloody bowel movements, along with nausea, vomiting, unable to maintain oral intake. Day 17 after vaccination, patient went to ED after fever of 100.5F. On presentation, she is afebrile, WBC 11.9, CRP 61.8, calprotectin 1840, Clostridioides difficile negative, GI Panel negative. CT showed severe colitis involving the left colon from splenic flexure to rectum. Colonoscopy showed erythematous, granular, hemorrhagic, and ulcerated mucosa in the entire examined colon. Terminal ileum, cecum, ascending, transverse, descending, sigmoid and rectum biopsies were negative for CMV, showed chronic active colitis. Patient received intravenous Methylprednisolone, then transited to oral Prednisone taper and resumed her Tofacitinib. Her symptoms gradually improved. Discussion: To our best knowledge, no report has shown the association of mRNA vaccine and UC flare-up. In general, non-live vaccines are safe for UC patients regardless of immunosuppressants usage. Live vaccines are also contraindicated Tofacitinib users like our patient. In the Pfizer COVID-19 vaccine trial, patients on immunosuppressive therapy were excluded. Given the temporal relationship between the vaccine and her flare-up in the setting of long-term remission history, we are concerned that the stress induced by the mRNA vaccine may increase the risk of flare-up. More studies need to be done to evaluate the safety profile of mRNA vaccine for UC patients on immunosuppressants.Figure 1.: A: Nodular mucosa in second portion of duodenum. B: Multiple ulcers in terminal ileum. C and D: 1.7 cm segment of terminal ileum circumferential bowel wall thickening with mucosal hyperenhancement and submucosal edema.

Computed tomography enterocolongraphy in assessment of degree of ulcerative colitis activity.

Inflammatory bowel diseases are gaining more interest in the past few years. Ulcerative colitis (UC) is a chronic disease that requires accurate follow-up for a good treatment plan. Colonoscopy alone cannot be efficient to detect disease extent and has a high risk of perforation in acute severe UC and toxic megacolon. Computed tomographic enterocolonography (CTE) is widely used now to detect intramural, extra-intestinal involvement and intestinal complications. Hence, this study aimed to evaluate CTE in the assessment of the degree of activity of UC. This cross-sectional study was carried on 50 UC patients, divided into 36 males and 14 females presented at the Gastroenterology Unit, Alexandria Main University, Faculty of Medicine. Assessment of UC activity was done to all patients on three levels; the ulcerative colitis disease activity index for the clinical level, ulcerative colitis endoscopic index of severity by endoscopy and pathologically by degree of neutrophilic invasion, crypt abscess or cryptitis, presence of oedema and mucosal surface ulceration, then CTE was done and the findings were compared with the histopathological findings. Bowel wall thickening in CTE was divided into: normal (<3 mm, score 0), mild (3-6 mm, score 1), moderate (6-9 mm, score 2) and severe (>9 mm, score 3). Mesenteric hyperaemia, mucosal hyper enhancement and enlarged pericolic lymph nodes were recorded. CTE findings in the form of bowel wall thickening and hyper enhancement were found in 74% of active cases and were correlated with all histopathological findings investigated in this study with high statistical significance except in chronic stages, whereas lymph node enlargement and mesenteric hyperaemia did not show statistical significance with disease activity. CTE is a good tool for diagnosing disease activity in UC.

Diagnostic role of computed tomography enterography (CTE) in assessment of intra-mural and extra-intestinal CT findings in active Crohn\u2019s disease (CD)

BackgroundCrohn’s disease (CD) is a ruinous bowel disease, which, if left uncured, leads to penetrating bowel complications. Computed tomography enterography (CTE) is nowadays accepted as a principal modality for the assessment of small bowel diseases. The aim of this study is to assess the role of CT enterography in the identification of intramural as well as extra-intestinal CT changes yielding more thorough data about the level and severity of the disease process thus planning appropriate treatment strategy.ResultsFrom March 2017 to January 2019, 50 patients in Cairo, Egypt, who had clinical manifestations of inflammatory bowel disease, were evaluated by MDCTE. CT image analysis was processed, including anatomical localization of bowel segments affection, assessment of mucosal thickening and hyper-enhancement, and extra-enteric affection. Diagnosis of Crohn’s disease (CD) was confirmed by endoscopy and histopathology; mucosal thickening was seen in 42 patients (84%), mucosal hyper-enhancement was seen in 44 patients (88%) while engorgement of vasa recta (comb’s sign) was seen in 38 patients (76%).ConclusionAlthough ileocolonoscopy is a proven sensitive method to detect mucosal injury and diagnose disease activity, it is limited by its maximal extent and inability to detect transmural complications as well as limited ability to assess deep bowel wall involvement. CT enterography (CTE) is a valuable technique in diagnostic evaluation of intramural and extra-intestinal involvement in Crohn’s disease (CD) during disease activity.

Use of Lumen-Apposing Metal Stents for Inflammatory Bowel Disease-Related Strictures at a Pediatric Center: A Case Series

Use of Lumen-Apposing Metal Stents for Inflammatory Bowel Disease-Related Strictures at a Pediatric Center: A Case Series

The Role of Multi-Detector Computed Tomography in Assessment of Chron’s Disease Progression: A Cross-sectional Study

Background:There is a lack of information regarding the correlation between multi-detector computed tomography [MDCT] findings and clinical activity of Chron’s disease. The aim of the work: In this study, we aimed to investigate the correlation between MDCT and the degree of activity of Chron’s disease [CD].Patients and Methods: In this prospective study, a total of 50 patients with CD were recruited The disease activity was assessed using the Crohn's Disease Activity Index [CDAI]. For MDCT evaluation, we used 256 Multislice CT scanners [Toshiba Medical System, Tochigi-ken, Japan].Results: Forty-five patients [90%] showed signs of activity, while the other five patients [10%] were in the remission state [showed no signs of activity]. The most common sign of activity was mucosal hyper enhancement [93.3%], followed by mucosal thickening [91%], mesenteric congestion [64.4%], and mesenteric lymphadenopathy [33.3%]. The association analysis showed that there was a statistically significant association between CDAI and signs of activity in MDCT [360 ±64.5 in patients with signs of activity vs. 206.9 ±145.6 in patients with no signs of activity; p 0.05].Conclusion: Our study showed that the findings of MDCT are significantly correlated with clinical activity score. Clinical and radiological predictors of sever disease need to be assessed as predictors in future studies

Systematic reporting of computed tomography enterography/enteroclysis as an aid to reduce diagnostic dilemma when differentiating between intestinal tuberculosis and Crohn's disease: A prospective study at a tertiary care hospital.

Background and AimCrohn's disease (CD) and intestinal tuberculosis (ITB) have similar symptomatology and overlapping features on imaging, endoscopy, and histopathology. It is important to differentiate ITB from CD to initiate correct medical management. This prospective study aimed to characterize imaging features on computed tomography enteroclysis/enterography (CTE) that help in differentiating ITB from CD.MethodsA total of 300 consecutive patients who underwent CTE with the suspicion of small bowel diseases were evaluated. CTE findings were documented on a detailed “CTE case record form” and were correlated with other investigations like endoscopy, histopathological and microbiological examination, and improvement on empirical therapy to arrive at a final diagnosis. Only confirmed cases of ITB/CD were included for further analysis.ResultsFinal diagnoses revealed that 61 patients had ITB, 24 had CD, 90 patients had a final diagnosis not related to ITB/CD, and 125 had no bowel‐related diseases. The sensitivity of CTE (ITB vs CD, 90.2 vs 91.6%) was higher than the sensitivity of ileocolonoscopy (ITB vs CD, 87 vs 83.3%). A homogenous pattern of bowel wall thickening and confluent bowel involvement were significantly more common in ITB. Stratified bowel wall thickening with mucosal hyperenhancement, skip lesions in the bowel, and a comb sign were significantly more common in CD. Stratified bowel wall enhancement with an intervening layer of fat was specifically (P < 0.001) seen in patients with CD, and necrotic (P = 0.002) and calcified (P = 0.055) lymph nodes were specifically seen in patients with ITB.ConclusionWe propose a systematic approach to the radiological differentiation of ITB from CD.

S1691 Colitis in a Rheumatologic Patient

INTRODUCTION: Although a known of cause diarrhea, the pyrimidine synthesis inhibitor leflunomide is a rare cause of overt pancolitis that presents a formidable diagnostic challenge. CASE DESCRIPTION/METHODS: A 46-year-old female with a medical history of psoriatic arthritis was admitted with a two-week history of progressive right upper-quadrant pain, frequent non-bloody diarrhea, tenesmus, and non-bloody emesis. Her immunosuppressant therapy included certolizumab for the past five years and leflunomide for the past 17 months. She denied use of other medications. Initial laboratory evaluation was significant for a mild leukocytosis, lipase of 476 U/L (normal: 12–61 U/L) and C-reactive protein of 50.8 mg/L (normal ≤8.0 mg/L). A stool pathogen panel including Clostridioides difficile was negative. RUQ ultrasound revealed cholelithiasis without cholecystitis. Computed-tomography imaging with contrast revealed no evidence of pancreatitis and mild wall thickening with mucosal hyperenhancement, consistent with ileocolitis (Figure A). A subsequent colonoscopy was notable for circumferential, contiguous inflammation throughout the colon but a normal terminal ileum. Sigmoidal inflammation was mild with a decreased vascular pattern, erythema, and mild friability (Figure B). Biopsy of the descending colon (Figure C) demonstrated surface erosion, crypt abscess (arrowhead) and destruction, and increased lamina propria inflammation without the chronic inflammation classically seen in inflammatory bowel disease. Cytomegalovirus immunostaining was negative. Symptoms persisted despite a three-day course of high-dose intravenous steroids. The decision was made to stop leflunomide, the disease-modifying anti-rheumatologic drug, due to select case reports documenting rare leflunomide-induced colitis. Symptoms improved within two weeks of drug cessation, with a reduction of stool frequency to two formed bowel movements daily, resolution of abdominal pain, and improvement of erythema on repeat flexible sigmoidoscopy. DISCUSSION: This case demonstrates the value of a comprehensive medication history and the diagnostic challenge of leflunomide-induced colitis. Patients with rheumatologic diseases are often on medications with adverse gastrointestinal effects, including biologics, steroids, NSAIDs and other immunomodulators. The lack of randomized studies, vague radiologic, endoscopic and histologic findings, as well as the variable onset after medication initiation makes leflunomide-induced colitis a challenging and rare diagnosis.Figure 1.: Abdominal CT with contrast revealing ileocolitis, mild wall thickening, and mucosal hyperenhancement of the entire colon, consistent with colitis.Figure 2.: Colonoscopy of sigmoid colon revealing mild inflammation with erythema, decreased vascular pattern, and mild friability.Figure 3.: Descending colon; biopsies show surface erosion, crypt abscesses and crypt destruction. There is also increased laminar propria inflammation (100x).

S1639 Graft vs Host Disease of the Upper and Lower Gastrointestinal Tracts After an Autologous Bone Marrow Transplant: Report of an Unusual Case

INTRODUCTION: Gastrointestinal autologous graft-versus-host disease (GVHD) has been reported in 13% of autologous stem cell transplant (auto-HCT) recipients in comparison to 40% of those who underwent allogenic-HCT. Involvement of both upper and lower GI tracts is a unique phenomenon in auto-GVHD. Herein, we present a case of biopsy-proven GVHD of the duodenum and colon after auto-HCT. CASE DESCRIPTION/METHODS: A 59-year-old male with newly diagnosed multiple myeloma of the lumbar spine received palliative radiation, followed by four cycles of chemotherapy with lenalidomide, bortezomib, and dexamethasone. He subsequently underwent auto-HCT. One month after auto-HCT, he was admitted with fever, nausea, vomiting, early satiety, diarrhea and generalized abdominal pain. Initial laboratory findings included a normal leukocyte count and mild acute kidney injury. Stool testing for infectious etiologies were negative. Additional studies were negative for Epstein–Barr virus, cytomegalovirus (CMV), parvovirus, and his thyroid function was normal. Computed tomography was remarkable for diffuse wall thickening with mucosal hyperenhancement of the entire large and small intestine. Subsequent upper endoscopy revealed atrophic, erythematous, flattened mucosa with petechia in the stomach and diffuse mucosal erythema of the duodenal bulb. Flexible sigmoidoscopy was notable for friable mucosa with altered vasculature, erythema and erosions. Histologic examination of the duodenal mucosa showed villous atrophy with increased number of crypt apoptosis and cryptitis, and active inflammation with the presence of crypt architecture distortion and numerous apoptotic bodies in the crypts of the colon. Immuno-stains for adenovirus and CMV were negative. The constellation of histomorphological features was consistent with GVHD and the patient was subsequently treated with a methylprednisolone taper, which resulted in almost complete resolution of his symptoms. DISCUSSION: GVHD represents an immunocompromised state as it reduces bowel integrity and may lead to severe infections with or without immune suppressive therapy treatment. Certain chemotherapy agents including lenalidomide, inhibit the proliferation and function of regulatory T cells, predisposing patients to GI auto-GVHD. As patients with GI auto-GVHD present with a variety of both upper and lower GI symptoms, we recommend performing endoscopic evaluation of both upper and lower GI tracts to ensure a timely diagnosis.Figure 1.: (A-B) Duodenum. A: Histologic sections of the duodenum shows abnormal villous architecture (arrows) consisting of shortening and widening. Lamina propria (star) cellularity is increased (hematoxylin and eosin stain; original magnification ×40). B: Higher magnification shows the crypts with increased number of apoptosis (arrows) (original magnification ×200). (C-D) Colon. C: Section of the colon shows marked crypt architectural distortion with the presence of acrypt abscesses (arrow). These features are those of chronic colitis with moderate activity (original magnification ×20). D: Colonic crypts show increased number of apoptosis (arrows) (origincal magnification ×200).

Colitis in a Rheumatologic Patient

Question: A 46-year-old woman with a medical history of psoriatic arthritis, antiphospholipid syndrome, and previous pulmonary embolism on warfarin was admitted with a 2-week history of progressive right upper quadrant pain, frequent nonbloody diarrhea, tenesmus, and nonbloody emesis. Her immunosuppressant therapy included certolizumab for the past 5 years and leflunomide for the past 17 months. She denied use of other medications. She has no personal or family history of inflammatory bowel disease. Initial laboratory evaluation (reference ranges in parenthesis) was significant for a mild leukocytosis of 12.6/L × 109/L (3.4–9.6 × 109/L), lipase of 476 U/L (12–61 U/L), C-reactive protein of 50.8 mg/L (≤8.0 mg/L), and a supratherapeutic international normalized ratio of 3.9 (0.9–1.1). Gastrointestinal pathogen panel including Clostridioides difficile was negative. Ultrasound examination of the right upper quadrant revealed cholelithiasis without cholecystitis and a poorly visualized common bile duct. Computed tomography imaging with contrast showed no evidence of pancreatitis and revealed mild wall thickening with mucosal hyperenhancement, consistent with ileocolitis. The patient underwent colonoscopy, which was notable for circumferential, contiguous inflammation throughout the colon, but a normal terminal ileum. Inflammation was described as mild with erythema, decrease in vascular pattern, and mild friability depicted in the sigmoid (Figure A). Cold forceps biopsy was performed from the terminal ileum and revealed surface erosion and increased lamina propria inflammation. The descending colon was also biopsied as shown in Figure B, demonstrating surface erosion, crypt abscess (arrowhead) and destruction, and increased lamina propria inflammation. No evidence of chronicity was noted. What is the most likely etiology of the patient’s colitis? Look on page 2035 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Colonic biopsy was negative for cytomegalovirus immunostaining and also lacked the chronic inflammation classically seen in inflammatory bowel disease. Symptoms persisted despite a 3-day course of high-dose intravenous steroids. The decision was made to stop leflunomide, the disease-modifying antirheumatologic drug, owing to select case reports documenting rare leflunomide-induced colitis.1Verschueren P. Vandooren A.K. Westhovens R. Debilitating diarrhea and weight loss due to colitis in two RA patients treated with leflunomide.Clin Rheumatol. 2005; 24: 87-90Crossref PubMed Scopus (21) Google Scholar,2Kwok A.M.F. Morosin T. Leflunomide-induced colitis in association with enterocutaneous fistula in an immunosuppressed patient with renal transplant and rheumatoid arthritis.Clin J Gastroenterol. 2019; 12: 310-315Crossref PubMed Scopus (5) Google Scholar Symptoms improved within 2 weeks of drug cessation, with a decrease of stool frequency to 2 formed bowel movements daily, resolution of abdominal pain, and improvement of erythema on repeat flexible sigmoidoscopy. Current prescribing information for leflunomide includes diarrhea and abdominal pain as side effects but, as seen in our patient, these symptoms may be dramatic and severe. Although the immunosuppressive properties of leflunomide as a pyrimidine synthesis inhibitor have been well-studied, the mechanism by which it induces colitis is not well understood.1Verschueren P. Vandooren A.K. Westhovens R. Debilitating diarrhea and weight loss due to colitis in two RA patients treated with leflunomide.Clin Rheumatol. 2005; 24: 87-90Crossref PubMed Scopus (21) Google Scholar Diagnostic challenges to leflunomide-induced colitis not only include its rarity, but also its late onset after medication initiation. In previously documented cases, symptoms of weight loss and diarrhea began 18–24 months after initiation of the drug—a similar timeline to our patient.1Verschueren P. Vandooren A.K. Westhovens R. Debilitating diarrhea and weight loss due to colitis in two RA patients treated with leflunomide.Clin Rheumatol. 2005; 24: 87-90Crossref PubMed Scopus (21) Google Scholar Additionally, patients with rheumatologic diseases are often on other medications with adverse gastrointestinal effects, including biologics, steroids, nonsteroidal anti-inflammatory drugs, and other immunomodulators, making a medication history pivotal for appropriate management. Moreover, there are no specific endoscopic or histologic findings that distinguish this disease from other causes of colitis, with previous reports describing a wide range of histologic changes. As such, the current mainstay for diagnosis appears to also be its treatment: symptomatic improvement after medication cessation.1Verschueren P. Vandooren A.K. Westhovens R. Debilitating diarrhea and weight loss due to colitis in two RA patients treated with leflunomide.Clin Rheumatol. 2005; 24: 87-90Crossref PubMed Scopus (21) Google Scholar, 2Kwok A.M.F. Morosin T. Leflunomide-induced colitis in association with enterocutaneous fistula in an immunosuppressed patient with renal transplant and rheumatoid arthritis.Clin J Gastroenterol. 2019; 12: 310-315Crossref PubMed Scopus (5) Google Scholar, 3Gunendo Z. Benli E. Gogus F. et al.Long term use of leflunomide as a cause of severe diarrhea?.Turk J Rheumatol. 2010; 25: 41-43Crossref Scopus (5) Google Scholar This case demonstrates an example of leflunomide-induced colitis which should be considered in patients who present with symptoms of abdominal pain and diarrhea in the setting of leflunomide use, even months to years after medication initiation.

A112 ANGIOEDEMA,A RARE YET AN IMPORTANT CAUSE OF ABDOMINAL PAIN. A CASE STUDY AND LITERATURE REVIEW

Abstract Background Abdominal pain is a common gastroenterological symptom with an extensive deferential diagnoses. Angioedema is an important cause to remember after the more common causes have been excluded.It is caused by a deficiency in the inhibitor of the first component of classical complement pathway and is divided into hereditary or acquired.Acquired angioedema is associated with autoimmune or lymphoproliferative neoplasms.The clinical features of both include recurrent,self-limiting and circumscribed edema affecting the subcutaneous tissue of the upper respiratory airways and gastrointestinal tract. Aims We describe an interesting case of acquired angioedema presenting with recurrent abdominal pain. We also systematically review the current literature on this rare entity. Methods A search of electronic databases was performed inclusive to September 2019, for all studies and reviews of patients with acquired angioedema manifested as recurrent attacks of abdominal pain. Results: Case Report: 65 year old lady ho has an at least 2 year long history of abdominal pain and bloating associated on some occasions with nausea and vomiting.She presented to our emergency department in August,2018 with a day history of severe generalized abdominal pain and was found to have circumferential thickening,edema with mucosal hyperenhancement involving the distal segment of the small bowel.Splenomegaly was noted on that study.A double balloon enteroscopy was planned,but ultimately cancelled as her ileitis had resolved.The patient was discharged home as her pain resolved with conservative management which included intravenous fluid, pain medications and antiemetics.She then represented to the hospital on September 16, 2019 severe abdominal pain and throat tightness associated with shortness of breath. Again,noted was an extremely short segment of ileum with mucosal edema and hyperenhancement which resolved on a repeat CT scan done during that admission on September 18th, 2019.In light of the patient’s symptoms,CT scan findings,progressive anemia, thrombocytopenia and splenomegaly. It was thought that her abdominal pain is related to secondary to angioedema driven by a lymphoproliferative process as evident by the splenomegaly and worsening cytopenia. A bone marrow was done which revealed clonal B, so the diagnosis of lymphoma was made. The patient’s C1 esterase was 0.2 with reduced functional activity.CH50 less 10 perecent. A diagnosis of acquired angioedema was made and the patient was started on BERINERT 3000 IU SQ every three days with 1500 IU for break through with significant improvement in the frequency and severity of abdominal pain episodes. Conclusions Acquired angioedema is to be considered as a cause of recurrent abdominal pain in a patient with a lymphoproliferative malignancy after common causes and etiologies have been ruled out. Funding Agencies None

1926 Gastrointestinal Bleeding in a Patient With Latent Tuberculosis and Remote T-Cell Lymphoma

INTRODUCTION: Immunosuppressed patients such as those with malignancies are susceptible to reactivation of tuberculosis (TB), which can affect the gut. CMV should also be considered as a cause of colitis in these patients. CASE DESCRIPTION/METHODS: A 68-year-old man with a history of T-cell lymphoma of the kidney and nasal cavity and latent TB presented with weight loss and cough. He was cachectic and had diffuse rhonchi in the lung bases. CT of the chest showed areas of cavitation. Multiple sputum cultures positive for acid-fast bacilli (AFB) and a positive mycobacterium tuberculosis (MTB) PCR confirmed active TB infection. The patient developed repeated episodes of melena with a hemoglobin level of 5.0 g/dL, MCV of 71.5 fL, iron of 4.5 ug/dL, transferrin saturation of 1%. Colonoscopy revealed extensive diverticulosis in the sigmoid colon and evidence of a prior cecectomy with ulceration of the ileocolonic anastomosis. Biopsies showed dense mature lymphocytic infiltrate and granulation tissue with no evidence of T-cell lymphoma. A CT revealed a 4 cm segment of terminal ileum with mild wall thickening, mucosal hyperenhancement and thickened folds of a distal loop of jejunum. Stool AFB culture and MTB PCR were both positive, indicating a probable diagnosis of TB enteritis. A push enteroscopy showed a 60 mm infiltrative lesion with ulcerated bases and three smaller lesions of similar appearance on the anterior wall of the stomach along with jejunal ulceration. Ulcer biopsies revealed large cells with inclusions consistent with CMV enteritis. Stains for AFB were also positive. Biopsies of the stomach lesions revealed an ulcerative oxyntic mucosa with dense atypical lymphoid infiltrate. Markers were consistent with a diagnosis of Burkitt’s Lymphoma (BL). The patient was treated with TB therapy, ganciclovir, and R-CHOP. DISCUSSION: Immunosuppression due to this patient’s BL likely led to dissemination and reactivation of latent TB and susceptibility to infection with CMV. The stomach and bowel are the most common sites of extranodal involvement in BL. The incidence of TB in malignancy is highest in non-Hodgkin’s lymphoma like BL. Bowel involvement in TB is seen in less than 5% of cases in the United States. Common endoscopic findings include ileal or ileocecal disease, non-confluent involvement of the colon, and nodular mucosa with areas of ulceration. The diagnosis can be made by biopsy showing caseating granulomas, a positive TB culture or PCR result, or by clinical suspicion with improvement following treatment.