Terminal Ileitis Research Articles

Henoch–Schönlein Purpura in Two Pediatric Patients Presenting as Terminal Ileitis

Keywords Henoch–Scho¨nlein purpura Terminal ileitis Acute abdomen ChildrenIntroductionHenoch–Scho¨nlein purpura (HSP) is a leukocytoclasticvasculitis characterized by a classic tetrad of nonthromb-ocytopenic palpable purpura, arthritis or arthralgias, andgastrointestinal and renal involvement [1]. HSP most oftenoccurs in children and its incidence between 4 and 6 yearsof age has been reported to be 20.4 cases per 100,000children [2]. Ninety percent of affected individuals are lessthan 10 years of age. Etiology is still obscure but somefactors such as vaccination, some foods, infection, andinsect stings have been thought to play a role in the path-ogenesis of HSP [3, 4].Gastrointestinal system symptoms such as abdominalpain, vomiting, or bleeding are observed in 50–75 % of thepatients [5, 6]. Abdominal pain precedes the rash in12–19 % of cases [6, 7]. Cases of HSP presenting as ter-minal ileitis are rarely encountered in childhood andtherefore this condition makes initial HSP diagnosis diffi-cult. Terminal ileitis has rarely been recognized in patientswith HSP. In the literature, to our knowledge, only nineadult HSP patients have been reported to date [8–11]. Inthis paper, due to its rarity, we present two cases of pedi-atric-onset HSP revealed by gastrointestinal involvement.We also intended to emphasize that the HSP diagnosis canbe more difficult when abdominal pain precedes the cuta-neous rash.Case 1An otherwise healthy 4-year-old boy applied to ouremergency service with complaints of vomiting andabdominal pain over the preceding 4 days. On physicalexamination, the patient was pale and mildly dehydrated.His blood pressure, body temperature, heart rate, andrespiratory rate were 110/60 mmHg, 37.5 C, 94 and26/min, respectively. Abdominal examination revealedtenderness, right lower quadrant pain upon palpation, andrebound tenderness. The rest of his physical examination

PWE-062 Terminal Ileal Intubation Over A Five Year Period; Was It Useful?

IntroductionThe value of routine ileoscopy during colonoscopy is unclear, but intubation of the terminal ileum (TI) is considered to be the main method of confirming completeness of colonoscopy. TI intubation...

PWE-103 Terminal Ileitis At Endoscopy In Clinical Practice: Is It Always Due To Crohn’s Disease?

IntroductionTerminal ileitis (TI) when identified at endoscopy is generally assumed to be secondary to Crohn’s disease (CD). However, TI may be due to other causes including infection, malignancy, radiation, vasculitis...

Su1115 Terminal Ileitis At Endoscopy in Clinical Practice: Is It Always Crohn's Disease?

Su1115 Terminal Ileitis At Endoscopy in Clinical Practice: Is It Always Crohn's Disease?

Diagnostic performance of contrast-enhanced MR for acute appendicitis and alternative causes of abdominal pain in children

Unenhanced MRI has emerged as a useful tool for diagnosing pediatric acute appendicitis. The use of contrast-enhanced MRI for diagnosing pediatric appendicitis has not been documented. The purpose of this study is to examine the diagnostic performance of contrast-enhanced MRI for acute appendicitis and alternative entities in the pediatric population presenting with acute abdominal pain. A retrospective review was conducted of 364 consecutive pediatric patients undergoing contrast-enhanced MRI for the evaluation of possible appendicitis at a single institution between November 2012 and September 2013. There were 132 cases of pathologically confirmed appendicitis out of 364 pediatric patients (36.3%) included in the study. Overall sensitivity and specificity were 96.2% (95% CI [91.4-98.4%]) and 95.7% (95% CI [92.3-97.6%]), respectively. Positive predictive value and negative predictive value were 92.7% (95% CI [86.6-96.3%]) and 97.8% (95% CI [94.7-99.1%]), respectively. The appendix was visualized in 243 cases (66.8%). Imaging confirmed alternative diagnoses in 75 patients, including most commonly colitis, enteritis or terminal ileitis (n = 25, 6.9%), adnexal cysts (n = 25, 6.9%) and mesenteric adenitis (n = 7, 1.9%). Contrast-enhanced MRI is capable of accurately diagnosing acute appendicitis while detecting many alternative entities of abdominal pain, and it allows good visualization of the appendix. Further evaluation is needed to determine whether contrast-enhanced MRI provides an advantage over non-enhanced MRI for imaging evaluation of acute abdominal pain in the pediatric population.

Lymphœdème génital associé à une maladie de Crohn

IntroductionCrohn's disease is a chronic inflammatory intestinal pathology which can be associated to different extra-digestive manifestations. We reported a case of recurrent genital lymphedema leading to Crohn's disease diagnosis. Case reportA 49-year-old man was referred for increased penis and scrotal volume, associated with recurrent febrile flare during the 10 previous years. Clinically, we noted an inflammatory penis and scrotum lymphedema. Clinical urological examination, and biological, bacteriological, computer-tomography examinations were negative. Metastatic Crohn's disease was diagnosed in association with concomitant severe terminal ileitis. Treatment with corticosteroids and azathioprine resulted in significant decrease of inflammatory genital lymphedema. ConclusionGenital inflammatory lymphedema occurs during inflammatory, infectious, and tumor diseases. Some cases of metastatic genital lymphedema related to Crohn's disease are described, most often in children. Inflammatory genital lymphedema associated with gastrointestinal symptoms may suggest Crohn's disease.

P129 Terminal ileitis – Is it Crohn's disease?

P129 Terminal ileitis – Is it Crohn's disease?

Functional Bowel Syndrome: Also a “Crohn” Disease?

Burrill R. Crohn (1884–1983), a pioneering gastroenterologist, is best known for a manuscript published in 1932 in the Journal of the American Medical Association, coauthored with Leon Ginzburg and Gordon Oppenheimer entitled ‘‘Terminal Ileitis: A New Clinical Entity’’ [2]. In this publication, he described 14 cases of a granulomatous inflammation of the distal ileum. Although descriptions of the condition had arguably been published previously, this landmark paper described clinical findings in the largest group of patients with inflammatory bowel disease at that time, and was the source of our current use of the author’s name for the disease. Dr. Crohn was an interesting man who practiced medicine into his 90s, primarily at the Mount Sinai Hospital in New York, where he worked for over 40 years. A true polymath, he also painted and studied Civil War history. Like many of his contemporaries, who worked when the field of gastroenterology was still in its infancy, his career was devoted to the understanding and management of a variety of vexing conditions, including peptic ulcer disease, gastrointestinal cancer, and functional bowel disorders. Dr. Crohn’s premise underlying his description of functional bowel disorders, republished in this issue of Digestive Diseases and Sciences [1], is that the gastrointestinal tract is a target for ‘‘external forces’’ including stress, personal problems, and family history that ultimately predispose to the development of what Dr. Crohn termed the ‘‘neurotic stomach.’’ Based on contemporary understanding of functional bowel disorders, this expression has a certain quaintness, as it reflects the prevailing interest in psychoanalytic theory. At the time of this manuscript’s publication, Sigmund Freud’s picture had already appeared on the cover of Time, and Freud’s name comes up twice in the article, beginning with its introductory sentence. Although our current understanding of functional bowel disorders includes a number of more recently appreciated non-psychiatric factors associated with the pathophysiology of these conditions, including intestinal dysbiosis, dysregulated gastrointestinal neurotransmitters, and distorted brain-gut activities, Dr. Crohn’s article contains many insights that remain relevant to the care of these patients in the twenty-first century. The article begins by suggesting that the burden of functional gastrointestinal (GI) conditions exceed that of the other major classes of organic diseases affecting the GI tract recognized at that time (ulcers, gallbladder disease, and cancer). Of interest, current literature supports this premise. In 2008, an annual total of 11,648,000 ambulatory care visits for functional gastrointestinal disorders in the United States occurred, compared with 7,578,000 visits for the other three GI conditions combined [3]. Dr. Crohn goes on to describe organic gastrointestinal disorders as having a basis in either secretory or motor abnormalities. Although we would certainly agree with the definition of ‘‘true cardiospasm’’ (achalasia) or gastric atonia as organic motor disorders, our lines today would be blurred in terms of defining these as functional versus organic disorders. On the other hand, we would likely not classify disorders of suspected psychiatric etiology, such as rumination syndrome or anorexia nervosa, as intrinsic gastrointestinal motor diseases, while we would recognize associated motility disturbances. The original article Functional and nervous disorders of the stomach and alimentary tract by Burrill B. Crohn published in American Journal of Digestive Diseases and Nutrition, October 1934, Volume 1, Issue 10, pp. 773–777. Springer.

Describing the Clinical Phenotypes of Crohn’s Disease: Lessons from the Past

Although there remains some confusion regarding the original description of the clinical entity that is currently termed Crohn’s disease, medical historians have cited clinical portrayals of what is likely the disease in the works of Hippocrates, Giovanni Batista Morgagni (1682–1771), John Abercrombie (1780–1844), Charles Combe (1743–1817), and William Saunders (1743–1817) [1–3]. In 1912, T.K. Dalziel of Glasgow described a disease of the intestine termed ‘‘chronic interstitial enteritis’’ in which chronic inflammatory changes associated with characteristic episodes of abdominal pain simulating intestinal obstruction were present [4]. Preceding its seminal description in the Journal of the American Medical Association (JAMA) [5], and references therein, a heterogeneous group of tumor-like inflammatory masses were documented by Tietze in an encyclopedic article in 1920 [6]. By 1923, Moschowitz and Wilenski from Mount Sinai Hospital in New York had described four cases of benign intestinal granuloma, with one having similarity to the original report of regional ileitis [7]. In the first of two presentations in May 1932, Leon Ginzburg presented, before a meeting of the American Gastro-Enterological Association and later published in an expanded form, a description of 52 cases of a granulomatous disease of the intestines without evidence of recognized diseases, including tuberculosis, syphilis, or actinomycosis [7]. A second presentation by Burrill Crohn entitled ‘‘Terminal Ileitis: Its Clinical Manifestations,’’ was delivered to the Section on Gastro-Enterology and Proctology of the American Medical Association in New Orleans, describing 14 patients, predominantly young adults, with stenosis of the distal ileum and fistulous disease to the large intestine or abdominal wall. Clinical symptoms resembled the known entity ulcerative colitis, while pathology demonstrated subacute or chronic necrotizing inflammation beginning abruptly at the ileocecal valve and extending orally for 8–12 inches (c. 20–30 cm), involving the distal ileum alone. In short order, the presentation, entitled ‘‘Regional Ileitis,’’ was published by Crohn, Ginzburg, and Oppenheimer to a wide audience in JAMA on October 15, 1932 [3, 5]. The original description of regional ileitis was timely and accepted by the medical community with immediate additions to the 14 original cases. J.A. Bargen from the Mayo Clinic offered the term ‘‘regional’’ as opposed to ‘‘terminal’’ ileitis, recalling similar cases and recognizing the ‘‘agonal’’ connotation of the descriptor ‘‘terminal’’ [5]. Julius Friedenwald of Baltimore and Louis Hirschman of Detroit added anecdotal cases similar to the descriptions of Crohn, with the addition of a relationship between a previous diagnosis of ulcerative colitis and granulomatous pathology of the terminal [5]. In Volume 1 of the American Journal of Digestive Diseases and Nutrition (and reprinted in part in this issue), Crohn describes in detail three cases of regional ileitis in his publication ‘‘The Broadening Conception of Regional Ileitis,’’ in an attempt to revise and expand the initial concepts of the diagnosis in the face of growing clinical experience [8]. The original article The broadening conception of regional ileitis by Burrill B. Crohn published in American Journal of Digestive Diseases and Nutrition, April 1934, Volume 1, Issue 2, pp. 97–99. Springer.

Change and Significance of IL-8, IL-4, and IL-10 in the Pathogenesis of Terminal Ileitis in SD Rat

The objective of the study is to explore change and significance of IL-8, IL-4 and IL-10 in the pathogenesis of terminal Ileitis in SD rat. 60 male SD rats were divided into model group, suture group, and control group equally. The rats subjected to ileum-cecum side-to-side anastomosis in terminal ileum in model group, suture in terminal ileum in suture group, and the control group accepted no special treatment. The terminal ileum tissue which was 1-3 cm from anastomotic stoma was collected at 2 and 8 weeks after surgery in each group. The pathological slice was observed under microscope, and PCR was applied to detect the expression of IL-4, IL-8, and IL-10 at different times. Pathological result showed that neutrophils significantly increased in model group and suture group at 2nd week, showing acute inflammatory reaction; model group showed chronic inflammation at 8th week. The change of IL-8, IL-4, and IL-10 expression level at 2 weeks after surgery: The IL-8 expression level of SD rat terminal ileum tissue in model group was significantly higher than in control and suture groups (P < 0.01), and it was higher in suture group compared to control group (P < 0.01); the expression level of IL-4 in control group was higher than model and suture groups (P < 0.05); there was no statistical significance between model group and suture group (P = 0.363); the expression level of IL-10 in control group was higher than in model and suture groups (P < 0.01), and it was higher in suture group compared to model group (P < 0.01). The change of IL-8, IL-4, IL-10 expression level at 8 weeks after surgery: The expression level of IL-8 significantly decreased in model group, and there was no significantly difference between three groups (P > 0.05); the expression level of IL-4 was higher in model group and suture group compared to 2nd week; there was no significance between three groups (P < 0.05); the expression of IL-10 was higher in model group compared to 2nd week (P < 0.01), it was lower than control group and suture group (P < 0.01); there was no significant difference between suture group and control group (P > 0.05). The chronic terminal ileum model could be successfully established by ileum-cecum side-to-side anastomosis in terminal ileum in SD rats; IL-8 can induce the inflammatory reaction in terminal ileitis and chemokines aggregation and mediate inflammatory reaction by mediating other inflammatory factors; as a proinflammatory cytokine, IL-8 can inhibit IL-10; IL-10 and IL-4 can inhibit the inflammatory reaction of terminal ileum.

P-017 YI Spontaneous Closure of Enterovesicular Fistula with Adalimumab

Crohn’s disease is a chronic inflammatory disorder which affects approximately 700,000 patients in the United States. Of these patients, up to 40% will have fistulizing disease, which represent a more aggressive phenotype often failing medical therapy and requiring surgery for definitive treatment. We present 2 cases of fistulizing Crohn’s disease complicated by entero vesicular fistula successfully treated with Adalimumab monotherapy. Case 1: 23 y/o male who presented to Walter Reed National Military Medical Center (WRNMMC) with a 4 month history of RLQ pain, relapsing fevers, pneumaturia and dysuria. Evaluation via CT Scan of the Abdomen was significant for long segment terminal ileitis with evidence of an entero-vesicular fistula. Colonoscopy showed nodular and erythematous terminal ileal mucosa with biopsies confirming Crohn’s ileitis. Cystoscopy revealed an area of erythematous and edematous mucosa along the posterior bladder wall. An initial prolonged course of Ciprofloxacin and Metronidazole partially improved symptoms. The patient was started on Adalimumab induction dosing followed by 40 mg subcutaneously bi-weekly with complete resolution of symptoms over the course of 2 months. Subsequent MRE showed no evidence of fistulous tract along with significant improvement in small bowel disease. The patient remains in clinical remission approximately 1 year after initiation of Adalimumab. Case 2: 27 y/o male who presented to WRNMMC with a 1 month history of dysuria, fecaluria, hematuria and scant hematochezia. Patient was initially evaluated at Landsthul Army Medical center, Germany where he underwent cystoscopy which showed evidence of ulcerative cystitis and a fistulous tract. Colonoscopy was significant for cobblestone appearing terminal ileum with ulcerated mucosa. Biopsies showed crypt abscess formation and distortion consistent with Crohn’s ileitis. Patient was initially placed on Ciprofloxacin and metronidazole with no improvement in symptoms. MR enterography (MRE) showed the presence of an entero-vesicular fistula with associated distal ileal inflammation. The patient was started on Adalimumab induction dosing followed by 40 mg subcutaneously every other week. Over the course of 4 months the patient reported complete resolution of all symptoms. Re-evaluation with cystoscopy was notable for no residual fistula and MRE approximately 8 months later demonstrated no evidence of an entero vesicular fistula. Enterovesicular fistulas occur in 2%–5% of patients with Crohn’s disease. When present, typical symptoms include recurrent urinary tract infections, pneumaturia and fecaluria. Surgical management is often necessary but can have serious complications such as perforation and abscess formation in as many as 12% of patients. In patients in whom medical management is attempted, there have been limited reported cases of successful closure of enterovesicular fistulas with anti TNF agents. These 2 cases represent the only reported sustained successful management of enterovesicular Crohn’s fistulas confirmed by both clinical response and radiographic evidence on anti-TNF therapy. The early use of anti-TNF in a patient presenting with a fistula (“top-down” approach) may be the reason fistulas healed so effectively. Use of anti-TNF therapy should be considered early in the treatment of fistulizing Crohn’s to include enterovesicular fistulas.

Terminal Ileal Intubation during Colonoscopy over a Five-Year Period: Was It Useful?

Purpose: The value of routine ileoscopy during colonoscopy is unclear, but intubation of the terminal ileum (TI) is considered to be the main method of confirming completeness of colonoscopy. TI intubation rates are variable and intubation is often omitted due to time constraints and the perception of little added diagnostic value. Our aim was to assess the diagnostic yield of TI intubation during colonoscopies at our institution. Methods: A retrospective study was undertaken at our institution. Colonoscopy data over a 5-year period (1st October 2007 to 30th September 2012), were retrieved from the Endoscopy Reporting System database (Unisoft, Enfield, UK). Patients with ileo-caecal resection were excluded. Demographic data, TI pathology (endoscopic and histopathologic), and indications for colonoscopy were analysed. Results: 8,016 colonoscopies were performed with an overall unadjusted caecal intubation rate of 90.3%. The endoscopists were of different grades including gastroenterologists, colorectal surgeons, and a nurse endoscopist; 206 with previous ileo-caecal resection were excluded. Further analysis was performed on 7,810 colonoscopies. Mean age was 61 years with a female preponderance at 52.6%. The TI was intubated in 1,845 (23.5%). Endoscopic TI pathology was identified in 42 patients (2.3%). Histology was available for 31, of which 23 (1.3%) had confirmed histological abnormalities. Diagnoses on ileoscopy included one adenocarcinoma, one carcinoid tumour, one metastatic malignant melanoma and 20 with terminal ileitis, of which, six had histological features of Crohn's disease. The most common indications in those with TI pathology were diarrhoea (15), abdominal pain (8), and rectal bleeding (8). Conclusion: Although overall diagnostic yield was low, TI intubation identified significant pathologies requiring further action, including three malignancies. Routine ileoscopy at colonoscopy is a simple manoeuvre, which, apart from quality assurance can identify important pathology. The most common indication in those with confirmed TI pathology was diarrhoea, therefore ileoscopy may have added diagnostic value in this context.

An Unusual Case of Terminal Ileitis and Stricture that Mimicked Crohnʼs Disease

Purpose: Chronic inflammation in the terminal ileum (TI) suggests a cause for the patient's symptoms, especially when the clinical suspicion is Crohn's disease. Non-steroidal anti-inflammatory drugs, lymphoid hyperplasia, intestinal infections, lymphoma, infections and ulcerative colitis (UC) are some of the other causes of terminal ileitis. This is an unusual case of a 41-year-old multiparous female with past medical history of small bowel obstruction and colitis who presented with a 5-day history of crampy abdominal pain, nausea, vomiting, and diarrhea. On the CT scan of the abdomen she was found to have small bowel obstruction with segmental enteritis in close proximity to the terminal ileum. She was started on IV antibiotics and steroids, kept NPO and NG tube was placed to relieve the obstruction. Due to little improvement in the obstruction, she underwent exploratory laparotomy with resection of the narrowed small bowel segment with side to side anastomosis and appendectomy. Patient was started on temporary parenteral feeding, and continued on IV steroids for management of suspected inflammatory bowel disease. Strangely, the pathology results for the small bowel resection specimens showed presence of endometriosis in both the appendix and terminal small bowel segment without any evidence of inflammatory bowel disease. Her steroids were soon tapered off and with tolerance of oral feeds patient was discharged from the hospital with outpatient gynecology follow-up for management of endometriosis. Ileal endometriosis should be carefully considered in the differential diagnosis of Crohn's disease in menstruating females, especially the ones who are nulliparous and have dysmenorrhea, dyspareunia, dyschezia, menometrorrhagia, or other peri-menstrual symptoms. This case exemplifies the importance to not mistake endometriosis for Crohn's disease as they each have different therapeutic management.

MRI diffusion-weighted imaging (DWI) in pediatric small bowel Crohn disease: correlation with MRI findings of active bowel wall inflammation

Restricted diffusion on diffusion-weighted imaging (DWI) sequences during magnetic resonance enterography (MRE) has been shown in segments of bowel affected by Crohn disease. However, the exact meaning of this finding, particularly within the pediatric Crohn disease population, is poorly understood. The purpose of this study was to determine the significance of bowel wall restricted diffusion in children with small bowel Crohn disease by correlating apparent diffusion coefficient (ADC) values with other MRI markers of disease activity. A retrospective review of pediatric patients (≤ 18 years of age) with Crohn disease terminal ileitis who underwent MRE with DWI at our institution between May 1, 2009 and May 31, 2011 was undertaken. All of the children had either biopsy-proven Crohn disease terminal ileitis or clinically diagnosed Crohn disease, including terminal ileal involvement by imaging. The mean minimum ADC value within the wall of the terminal ileum was determined for each examination. ADC values were tested for correlation/association with other MRI findings to determine whether a relationship exists between bowel wall restricted diffusion and disease activity. Forty-six MRE examinations with DWI in children with terminal ileitis were identified (23 girls and 23 boys; mean age, 14.3 years). There was significant negative correlation or association between bowel wall minimum ADC value and established MRI markers of disease activity, including degree of bowel wall thickening (R = (-)0.43; P = 0.003), striated pattern of arterial enhancement (P = 0.01), degree of arterial enhancement (P = 0.01), degree of delayed enhancement (P = 0.045), amount of mesenteric inflammatory changes (P < 0.0001) and presence of a stricture (P = 0.02). ADC values were not significantly associated with bowel wall T2-weighted signal intensity, length of disease involvement or mesenteric fibrofatty proliferation. Increasing bowel wall restricted diffusion (lower ADC values) is associated with multiple MRI findings that are traditionally associated with active inflammation in pediatric small bowel Crohn disease.

Difficulties in diagnosing terminal ileitis due to Yersinia pseudotuberculosis

We report three patients with terminal ileitis and positive fecal cultures with Yersinia pseudotuberculosis. From one patient, a virulence plasmid (pYV)-negative Y. pseudotuberculosis was isolated, which represents the second finding of a pYV-negative isolate associated with human disease. All patients were treated with ciprofloxacin and fully recovered. Since conventional culture methods for yersiniosis are gradually replaced with molecular tests not recognizing Y. pseudotuberculosis, we recommend to include a specific culture medium or to apply a specific polymerase chain reaction (PCR) assay on fecal samples from patients suspected of terminal ileitis.

Shewanella putrefaciens bacteraemia associated with terminal ileitis

Shewanella putrefaciens has a wide geographical distribution, including sea- and fresh water, fish and soil, but it is an unusual pathogen in humans. A previously healthy boy without known immunodeficiency presented with fever, abdominal pain and diarrhoea, and a mass in the right lower quadrant. Terminal ileitis was confirmed by MRI and Shewanella putrefaciens was isolated from two separate blood cultures. This is the first report of terminal ileitis associated with Shewanella putrefaciens septicaemia.

Terminal Ileitis in Crohn's Disease Is Detected by Capsule Endoscopy

This is an example of capsule endoscopy (CE) revealing terminal ileitis in an young male patient with recurrent abdominal pain who had previously been investigated with colonoscopy and esophagogastroduodenoscopy without any significant findings. CE revealed severe inflammation of the terminal ileum. This article is part of an expert video encyclopedia.

The diagnostic value of colonoscopy for chronic diarrhea

Objective To evaluate the diagnostic value of colonoscopy for patients with chronic di- arrhea. Methods Data of 2449 patients with chronic diarrhea who underwent colonoscopy from January, 1999 to December, 2008 were reviewed. A total of 2110 patients who underwent colonoscopy screening for health checkup during the same period were used as controls. The rates of clinic-relevant abnormal endoscop- ic findings and negative finding were compared between two groups. Results Lesions with clinic signifi- cance were found in 44. 1% of patients with chronic diarrhea （1080/2449） and in 41.7% of controls （870/2110, X2 = 2. 756, P = 0. 097）. Compared with controls, incidence of non-IBD and noninfectious co- litis （X2 =58. 578, P 〈 0. 001 ）, IBD （X2 = 59. 609, P 〈 0. 001 ）, malignant tumor （X2 = 21. 649, P 〈 0. 001 ）, terminal ileitis （X2 =6. 275, P =0. 012）, infectious colitis （X2 = 17.019, P 〈0. 001 ）, intestinal tuberculosis （X2 = 7. 021, P = 0. 008 ）, melanosis coli （X2 = 6. 040, P = 0. 014 ） and parasitic infection （X2 = 4. 245, P = O. 039 ） were all significantly higher in patients with chronic diarrhea. However, inci- dences of adenomatous polyps （X2 = 14. 124, P 〈 0. 001 ） , non-adenomatous polyps 0（2 = 33. 427, P 〈 0. 001 ） and diverticular disease （X2 = 9. 921, P = 0. 002 ） were significantly higher in the control group. There was no significant difference in incidences of the benign tumor （X2 = 1. 627, P = O. 202 ） and an- giodysplasia （X2 = 0. 231, P = 0. 631 ） between the two groups. The overall screening rate of colonic polyps, divertieulosis, and vascular lesions was 37.3% in chronic diarrhea group. Conclusion Colonic polyps, di- verticulitis, benign tumors and angiodysplasia may not be the causes of chronic diarrhea. Etiology of more than 1/3 patients with chronic diarrhea remains unknown after eolonoscopy. Key words: Chronic diarrhea; Colonoscopy; Organic colonic lesions

When Nature Meets Nurture: Persistent Yersinia Infection

PRESENTATION When the patient’s symptoms are alleviated, it might seem that the causative infection has cleared. But that was not the case for a 62-year-old man with type 2 diabetes who presented with a 1-week history of constipation, lower abdominal cramping, rectal pressure, and hematochezia. In the emergency department, laboratory testing detected leukocytosis with a white blood cell count of 19 x 10 cells/mm and an elevated neutrophil count. Computed tomography (CT) of the patient’s abdomen and pelvis demonstrated marked inflammation of the rectal wall. He was admitted and underwent colonoscopy, which confirmed the presence of proctitis but was otherwise normal. Four days after admission, his stool culture grew pan-sensitive Yersinia enterocolitica. A diagnosis of Yersinia proctitis was made. Simple hepatic cysts seen on CT were felt to be incidental. The patient was prescribed a 5-day course of oral ciprofloxacin. He returned home and had complete symptom resolution. However, 3 weeks after completing treatment, he experienced gradual onset of severe pain that began in the right upper quadrant of the abdomen and radiated to his back and right shoulder. This was accompanied by malaise, intermittent fevers, and anorexia. He reported a 21-pound unintentional weight loss over the preceding 2 months. One month after discharge, he returned to the emergency department.

Combined Use of Modified Alvarado Score and USG in Decreasing Negative Appendicectomy Rate: Critical Appraisal of Data

Dear Sir, We have read the original article “Combined use of modified Alvarado score and USG in decreasing negative appendicectomy rate” by Nautiyal H, Ahmad S, Keshwani NK, and Awasthi DN in the January–February issue, 2010 [1]. We find it obligatory to report some inconsistencies in the article. The authors have not organized the data in a format fit for publication but have submitted 13 tables as is usually done in the case of a postgraduate thesis. The article has not included a “Result” section. Few references are not in accordance with journal style (reference numbers 21, 24, and 27). The number of patients who underwent surgical exploration/appendicectomy is not mentioned. Fifteen of the 50 patients are shown to have other pathologies; it is not mentioned (1) whether these patients were operated upon or not, appendicectomy was performed or not, and (2) how and when the diagnosis of these pathologies, including abdominal tuberculosis, terminal ileitis, Meckel's diverticulitis, was made. The data presented in 13 tables are not consistent and do not inspire confidence. In table 4a and 4b, 37 patients are shown to have undergone appendicectomy including five who underwent interval appendicectomy. It is not mentioned why these five patients, who were required to undergo appendicectomy according to the treatment plan, were treated conservatively, breaching the protocol. It has not been mentioned why these five patients undergoing interval appendicectomy later have been included in the study and how these patients were treated while analyzing the data. Table 13 which deals with pathological types of acute appendicitis does not include tubercular appendicitis as shown in figure 4. Clarifications from the authors will be highly appreciated concerning these issues. We hope further inputs from the authors explaining these deficiencies will help readers of this esteemed journal in understanding this valuable work further.