Accepted Manuscript An unexpected cause of terminal ileitis Femme Harinck, MD PhD, Paul G. van Putten, MD PhD, Joany E. Kreijne, MD, Marco J. Bruno, MD PhD, C Janneke van der Woude, MD PhD, Annemarie C. de Vries, MD PhD PII:
S0016-5107(16)30646-0
DOI:
10.1016/j.gie.2016.10.001
Reference:
YMGE 10268
To appear in:
Gastrointestinal Endoscopy
Received Date: 29 July 2016 Accepted Date: 2 October 2016
Please cite this article as: Harinck F, van Putten PG, Kreijne JE, Bruno MJ, van der Woude CJ, de Vries AC, An unexpected cause of terminal ileitis, Gastrointestinal Endoscopy (2016), doi: 10.1016/ j.gie.2016.10.001. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Title An unexpected cause of terminal ileitis
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Authors Femme Harinck MD PhD Paul G van Putten MD PhD Joany E Kreijne MD Prof. Marco J Bruno MD PhD Prof. C Janneke van der Woude MD PhD Annemarie C de Vries MD PhD
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Corresponding author Femme Harinck E-mail: [email protected] Phone: +31 (0)6 4300 5696 ‘s Gravendijkwal 230 3015 CE Rotterdam The Netherlands
ACCEPTED MANUSCRIPT An unexpected cause of terminal ileitis
Femme Harinck MD PhD, Paul G van Putten MD PhD, Joany E Kreijne MD, Marco J Bruno MD PhD, C Janneke van der Woude MD PhD, Annemarie C de Vries MD PhD
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Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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A 20-year-old female patient with Crohn’s disease (CD) who had a positive family history of CD was referred to our hospital because of therapy refractory CD. She was diagnosed with CD 2 years before referral. The initial diagnosis was made based on clinical presentation and the results of ileocolonoscopy, which showed erosions in the terminal ileum. Pathological examination of these lesions showed chronic inflammation without granulomas. At the moment of referral, she was treated with budesonide 9 mg once daily for over a year. Shortly after the first outpatient visit at our hospital, she was admitted with generalized abdominal pain, vomiting, and bloody stools. Laboratory inflammatory parameters showed no abnormalities, and fecal cultures were negative. Ileocolonoscopy showed erosions in the terminal ileum. To evaluate the presence of a stenosis, a computed tomographic enterography (CTE) was performed. CTE showed a thickened bowel wall at the terminal ileum over a length of 3 cm with a stenotic aspect and prestenotic dilatation. Because these findings were inconsistent with the endoscopic findings, a distal enteroscopy (double-balloon endoscope (Fujifilm EN-580T)) was performed for both diagnosis and possibly endoscopic dilatation of the stenosis. Surprisingly, enteroscopy revealed a diverticulum, located 60 cm proximal of the ileocecal valve with a mucosal bridge, a nummular lesion within the diverticulum and small erosions surrounding the diverticulum. Furthermore, enteroscopy showed erosions and an ulcer in the ileum distal to the diverticulum, without stenosis. Biopsies of the nummular lesion in the diverticula showed chronic inflammation and heterotopic remains of gastric mucosa (Figure 1). A diagnosis of Meckel’s diverticulum was made. After surgical resection of the diverticulum, this patient was asymptomatic. Legend Video: Distal enteroscopy showing a Meckel’s diverticulum at 60 cm proximal of the Ileocecal valve Figure 1: Histopathology of the nummular lesion within the ileal diverticulum showing gastric glands (arrow) containing typical gastric oxyntic chief cells. There is a little inflammation in the lamina propria (H&E staining, orig. mag. x200).
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ACCEPTED MANUSCRIPT
S0016-5107(16)30646-0
DOI:
10.1016/j.gie.2016.10.001
Reference:
YMGE 10268
To appear in:
Gastrointestinal Endoscopy
Received Date: 29 July 2016 Accepted Date: 2 October 2016
Please cite this article as: Harinck F, van Putten PG, Kreijne JE, Bruno MJ, van der Woude CJ, de Vries AC, An unexpected cause of terminal ileitis, Gastrointestinal Endoscopy (2016), doi: 10.1016/ j.gie.2016.10.001. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Title An unexpected cause of terminal ileitis
RI PT
Authors Femme Harinck MD PhD Paul G van Putten MD PhD Joany E Kreijne MD Prof. Marco J Bruno MD PhD Prof. C Janneke van der Woude MD PhD Annemarie C de Vries MD PhD
AC C
EP
TE D
M AN U
SC
Corresponding author Femme Harinck E-mail: [email protected] Phone: +31 (0)6 4300 5696 ‘s Gravendijkwal 230 3015 CE Rotterdam The Netherlands
ACCEPTED MANUSCRIPT An unexpected cause of terminal ileitis
Femme Harinck MD PhD, Paul G van Putten MD PhD, Joany E Kreijne MD, Marco J Bruno MD PhD, C Janneke van der Woude MD PhD, Annemarie C de Vries MD PhD
RI PT
Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
AC C
EP
TE D
M AN U
SC
A 20-year-old female patient with Crohn’s disease (CD) who had a positive family history of CD was referred to our hospital because of therapy refractory CD. She was diagnosed with CD 2 years before referral. The initial diagnosis was made based on clinical presentation and the results of ileocolonoscopy, which showed erosions in the terminal ileum. Pathological examination of these lesions showed chronic inflammation without granulomas. At the moment of referral, she was treated with budesonide 9 mg once daily for over a year. Shortly after the first outpatient visit at our hospital, she was admitted with generalized abdominal pain, vomiting, and bloody stools. Laboratory inflammatory parameters showed no abnormalities, and fecal cultures were negative. Ileocolonoscopy showed erosions in the terminal ileum. To evaluate the presence of a stenosis, a computed tomographic enterography (CTE) was performed. CTE showed a thickened bowel wall at the terminal ileum over a length of 3 cm with a stenotic aspect and prestenotic dilatation. Because these findings were inconsistent with the endoscopic findings, a distal enteroscopy (double-balloon endoscope (Fujifilm EN-580T)) was performed for both diagnosis and possibly endoscopic dilatation of the stenosis. Surprisingly, enteroscopy revealed a diverticulum, located 60 cm proximal of the ileocecal valve with a mucosal bridge, a nummular lesion within the diverticulum and small erosions surrounding the diverticulum. Furthermore, enteroscopy showed erosions and an ulcer in the ileum distal to the diverticulum, without stenosis. Biopsies of the nummular lesion in the diverticula showed chronic inflammation and heterotopic remains of gastric mucosa (Figure 1). A diagnosis of Meckel’s diverticulum was made. After surgical resection of the diverticulum, this patient was asymptomatic. Legend Video: Distal enteroscopy showing a Meckel’s diverticulum at 60 cm proximal of the Ileocecal valve Figure 1: Histopathology of the nummular lesion within the ileal diverticulum showing gastric glands (arrow) containing typical gastric oxyntic chief cells. There is a little inflammation in the lamina propria (H&E staining, orig. mag. x200).
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ACCEPTED MANUSCRIPT
