Multiple ulcers in the terminal ileum
 
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Ira Shah
Consultant in Pediatric Infectious Diseases and Pediatric Hepatology, Nanavati Hospital and Incharge Pediatric HIV, TB and Liver Clinics, B J Wadia Hospital for Children, Mumbai, India.

Address for Correspondence: Dr Ira Shah, 1, B Saguna, 271, B St Francis Road, Vile Parle {W}, Mumbai 400056.


Clinical Problem :
A 16 years old boy presented with abdominal pain and intermittent low grade fever for 3-4 months. An ultrasound {USG} abdomen showed multiple lymphnodes with bowel wall thickening of ascending colon, caecum, terminal ileum and appendix. There were no altered bowel habits on history. CT abdomen showed circumferential mural thickening involving distal ileum, caecum, proximal ascending colon with mesenteric non-necrotic lymphnodes {2.1 x 1.3 cm largest node}. Ileocolonoscopy showed ulcers in terminal ileum with granulation on gross appearance. Histopathological examination revealed non-specific inflammatory ulcers with no caseous necrosis or tuberculosis {TB}. He was advised intestinal resection of the diseased segment by the treating surgeon and so he presented to us for a second opinion. He had already been started on antituberculous therapy {ATT} for past 20 days. On presentation to us, his weight was 39.8 kg. He had pain and tenderness in right iliac fossa. Other systems were normal. Mantoux test was negative. Hemogram and ESR were normal. He had not been exposed to non-steroidal anti-inflammatory drugs {NSAIDS}.


Question :
What is the cause of ulcers in the small intestine_? Is it really TB_?

Expert Opinion :
Unlike other parts of the gastrointestinal tract, neoplasms are rare in the small intestine. {1} Non-specific small intestinal ulcers are usually caused by thiazides, potassium tablets or NSAIDs. {2} Cryptogenic multifocal ulcerous stenosing enteritis {CMUSE} is a characterized by non-specific stenosis and superficial ulcers. {3} It is characterized by unexplained small intestinal strictures found in adolescents and middle aged subjects, superficial ulceration of the mucosa and submucosa, chronic or relapsing clinical course even after surgery, no biological signs of systemic inflammatory reaction, along with beneficial effect of steroids. {3} CMUSE is different from chronic non-specific ulcer of small intestine {CNSU}. {4} CNSU is characterized by persistent anemia for more than 1 year, absence of clinical evidence suggestive of mycobacterial infection, absence of clinical evidence suggestive of Crohn’s disease, and lack of any dermatologic, ophthalmologic or genital symptom suggestive of Behcet’s disease with presence of non-specific intestinal ulcers. {1} Our patient also had no clinical evidence of TB or Crohn’s disease nor features suggestive of Behcet disease though he had no anemia. He also had no strictures. Thus, he did not fit classically into CMUSE or CNSU but was diagnosed to have non-specific ulcers of small intestine. The abdominal lymphnodes were also non-necrotic, suggestive of non-specific inflammation. He was started on steroids and ATT was stopped. After a month, his weight had increased to 41.7 kg, USG abdomen showed same amount of bowel thickening but nodes had regressed in size to 0.9 x 0.7 cm. His pain had also decreased.

References
1. Matsumoto T, Iida M Matsui T, Yao T, Watanabe H, Yao T et al. Non-specific multiple ulcers of the small intestine unrelated to non-steroidal anti-inflammatory drugs. J Clin Pathol 2004`57:1145-1150
2. Morris A . Nonsteroidal anti-inflammatory drug enteropathy. Gastrointest Endosc Clin N Am1999`9:125–33.
3. Perlemuter G, Guillevin L, Legman P, et al. Cryptogenic multifocal ulcerous stenosing enteritis. An atypical type of vasculitis or a disease mimicking vasculitis_? Gut 2001`48:333–8.
4. Chen Y, Ma W-Q, Chen J-M, Cai J-T. Multiple chronic non-specific ulcer of small intestine characterized by anemia and hypoalbuminemia. World J Gastroenterol. 2010`16:782-784.


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