BACKGROUND/AIMS: It remains uncertain which patients with stricturing-type Crohn's disease (CD) require early small bowel surgery after the initial diagnosis. We aimed to clarify clinical characteristics associated with the intervention in such condition of CD. METHODS: We retrospectively evaluated the clinical course of 53 patients with CD and small bowel strictures who were initially treated with medications after the initial diagnosis. We investigated possible associations between small bowel surgery and the following: clinical factors and radiologic findings at initial diagnosis and the types of medications administered during follow-up. RESULTS: Twenty-eight patients (53%) required small bowel resection during a median follow-up period of 5.0 years (range, 0.5–14.3 years). The cumulative incidence rates of small bowel surgery at 2, 5, and 10 years were 26.4%, 41.0%, and 63.2%, respectively. Univariate analysis indicated that obstructive symptoms (P=0.036), long-segment stricture (P<0.0001), and prestenotic dilation (P<0.0001) on radiography were associated with small bowel surgery, and immunomodulatory (P=0.037) and biological therapy (P=0.008) were significant factors during follow-up. Multivariate analysis revealed that long-segment stricture (hazard ratio [HR], 4.25; 95% confidence interval [CI], 1.78–10.53; P=0.001) and prestenotic dilation (HR, 3.41; 95% CI, 1.24–9.62; P=0.018) on radiography showed a positive correlation with small bowel surgery, and biological therapy (HR, 0.40; 95% CI, 0.15–0.99; P=0.048) showed a negative correlation. CONCLUSIONS: CD patients with long-segment stricture and prestenotic dilation on radiography seem to be at a higher risk of needing small bowel surgery. For such patients, early surgical intervention might be appropriate, even at initial diagnosis.
Biological Therapy ; Constriction, Pathologic ; Crohn Disease ; Diagnosis ; Follow-Up Studies ; Humans ; Incidence ; Intestine, Small ; Multivariate Analysis ; Radiography ; Retrospective Studies

OBJECTIVETo evaluate the diagnostic value of preoperative CT enterography (CTE) on obstruction, fistula and abscess formation compared to intraoperative findings in patients undergoing surgery for Crohn's disease(CD), aiming to provide reference to clinical practice.

METHODSPreoperative CTE data of 176 CD patients confirmed by clinic, endoscopy, imaging, operation and pathology at the Department of General Surgery in Nanjing Jinling Hospital from January 2013 to December 2015 were enrolled in retrospective cohort study. All the patients underwent enhanced full abdominal CT scan using SIMENS SOMATOM Definition Flash 64 row dual-source CT machine. CTE scans were performed from the dome of diaphragm to the symphysis pubis. The CT images in arterial and venous phase were reconstructed with 1.0 mm thin layer, and then processed in MMWP 4.0 workstation including multi-planar recombination, surface recombination and maximum density projection. The sensitivity, specificity, positive and negative predictive value, false negative rate and accuracy of preoperative CTE on obstruction, fistula and abscess were compared with intraoperative findings.

RESULTSAmong 176 patients, 122 were males and 54 were females with median age of 29 (18 to 65) years, median disease duration of 48 (1 to 240) months, median time interval from CT scan to operation of 16(1 to 30) days, and median body mass index of 17.8 (10.8 to 34.7) kg/m. Twenty-six cases (14.8%) had nutritional risk (NRS2002≥3); 23 cases (13.1%) had lesions limited to ileum; 19 cases (10.8%) had lesions limited to colon; 126 cases (71.6%) had simultaneous lesions of ileum and colon, and 8 cases (4.5%) had lesion in upper gastrointestinal tract. A total of 199 lesions of small intestine were identified by preoperative CTE, including 131 of obstruction (65.8%), 42 of fistula (21.1%), and 26 of abscess (13.1%), while 235 lesions were confirmed by operation, including 133 of obstruction (56.6%), 74 of fistula (31.5%), 28 of abscess (11.9%). The modification of planned surgical procedure due to unexpected intraoperative findings were found in 29(16.5%) patients. The sensitivity, specificity, positive predictive value and negative predictive value of preoperative CTE were 86.4%, 78.8%, 86.9% and 76.0% for obstruction; 83.8%, 79.1%, 67.5% and 90.4% for fistula; and 96.2%, 98.0%, 90.1% and 99.3 for abscess, respectively.

CONCLUSIONPreoperative CTE can effectively evaluate the lesions of intestinal obstruction, fistula and abscess in CD patients, with the highest accuracy of abscess, and has quite good consistency with intraoperative findings, which may be used as the first choice of imaging diagnosis of CD.

Abscess ; diagnostic imaging ; Adult ; Aged ; Colon ; diagnostic imaging ; surgery ; Crohn Disease ; diagnostic imaging ; surgery ; Female ; Humans ; Ileum ; diagnostic imaging ; surgery ; Intestinal Fistula ; diagnostic imaging ; Intestinal Obstruction ; diagnostic imaging ; Intestine, Small ; diagnostic imaging ; surgery ; Male ; Middle Aged ; Radiography, Abdominal ; methods ; statistics & numerical data ; Retrospective Studies ; Sensitivity and Specificity ; Tomography, X-Ray Computed ; methods ; statistics & numerical data

Small intestine intussusception in adults is a rare condition mainly caused by primary or metastatic small intestine malignancy. Here, we present a 72-year-old male patient who was diagnosed with small intestine cancer that was presented as small intestine intussusception on hybrid 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT). The patient was initially referred for an abnormality on a chest radiography and severe anemia. FDG PET/CT showed the lung lesion in the right upper lobe of lung as a high FDG uptake mass. Accidentally, FDG PET demonstrated another intense hypermetabolic intraluminal lesion in the small intestine accompanied with intussusception shown as a circumferential hypermetabolic wall. By pathologic examination, the patient was diagnosed as primary small intestine cancer with lung metastasis. This case highlights usefulness of hybrid FDG PET/CT to identify unexpected malignancy.
Adult ; Aged ; Anemia ; Carcinoma ; Electrons ; Humans ; Intestine, Small ; Intussusception ; Lung ; Male ; Neoplasm Metastasis ; Positron-Emission Tomography and Computed Tomography ; Radiography ; Thorax

BACKGROUND/AIMS: The incidence of adult small bowel intussusception detected at CT has increased with advanced imaging techniques and universal utilization of CT scan. We aimed to identify factors that could predict the necessity of surgical intervention in adult patients with small bowel intussusception detected at CT during the past decade. METHODS: There were 39 cases of adult small-bowel intussusception detected at CT from January 2004 to June 2014. The data on clinical factors, radiological factors and outcomes were collected by retrospectively reviewing all available medical records. Patients were classified as surgical group and conservative group according to the outcome. Association between predictive factors and outcome was assessed by Fisher's exact test and logistic regression models. RESULTS: Among a total of 39 patients, there were 32 patients (82%) in the conservative group and 7 patients (18%) in the surgical group. Spontaneous reduction was confirmed at short-term follow-up studies (abdominal ultrasonography [n=14], single contrast small bowel series [n=14], CT [n=4]) in the conservative group. No recurrence occurred during the median follow-up period of 14.1 months (range, 0-67.5 months). Patients in the surgical group had significantly higher white blood cell (WBC) counts (OR 1.001, p=0.048), more frequent obstruction (n=4 vs. n=4, p=0.022) or leading point (n=5 vs. n=0, p<0.001) and longer intussuception length (OR 1.929, p=0.032). CONCLUSIONS: Factors associated with the necessity to resort to surgical intervention in adults with small bowel intussusceptions were higher WBC counts, presence of obstruction or leading point, and longer intussuception length. Conservative management can be considered with short-term follow-up for those without these predictive factors.
Abdomen/diagnostic imaging ; Adult ; Aged ; Aged, 80 and over ; Diagnosis, Differential ; Female ; Follow-Up Studies ; Humans ; Intestine, Small/*diagnostic imaging ; Intussusception/*diagnostic imaging/surgery/therapy ; Leukocyte Count ; Male ; Middle Aged ; Odds Ratio ; Radiography, Abdominal ; Retrospective Studies ; Tomography, X-Ray Computed ; Ultrasonography

Ischemic enteritis is caused by either the interruption or significant reduction of arterial inflow to the small intestine. Risk factors are old age, diabetes mellitus and cardiovascular disease. It is very rare in young patients. We experienced a 21-year-old man with recurrent acute ischemic enteritis who was diagnosed with capsule endoscopy. He had previously taken medications for pulmonary hypertension and obstruction of both carotid arteries, and about 20 months earlier, he had been admitted due to hematochezia. Two sessions of angiography did not reveal the cause of hematochezia. At that time, capsule endoscopy showed mucosal edema and erythema in the terminal ileum, suggesting healed ischemic enteritis. The patient was admitted again due to hematochezia. Abdominal computed tomography showed focal celiac trunk stenosis and diffuse wall thickening of the small intestine, suggesting ischemic enteritis. Capsule endoscopy showed multiple active ulcers and severe hemorrhage with exudate, extending from the proximal jejunum to the terminal ileum. Using capsule endoscopy, the patient was diagnosed with acute extensive ischemic enteritis. Because endoscopic images of ischemic enteritis have rarely been reported, we report a case of a 21-year-old man who was diagnosed acute extensive ischemic enteritis with capsule endoscopy.
Angiography ; Capsule Endoscopy ; Enteritis/complications/*diagnosis/radiography ; Gastrointestinal Hemorrhage/etiology ; Humans ; Intestine, Small/pathology ; Male ; Tomography, X-Ray Computed ; Young Adult

The metastatic calcification is defined as the deposition of calcium salt in normal tissue with an abnormal serum biochemical environment, such as chronic kidney disease, hyperparathyroidism, and hypercalcemia related with malignancy. Although the metastatic calcification can develop in any organs and tissues, presenting its symptoms and complications are rare. Thus a few cases have been reported. This case shows the metastatic calcification of the small intestine without any peritoneal and mesenteric vascular calcification which was early diagnosed by computed tomography and mesenteric angiography in a patient with abdominal pain, receiving continuous ambulatory peritoneal dialysis due to end stage renal disease. The clinician should early consider the metastatic calcification as differential diagnosis when unidentified calcifications are noted in simple abdominal X-ray such as in the present case, and promptly confirm it by using appropriate diagnostic tests in order to prevent its complications and progression.
Calcinosis/*diagnosis/drug therapy/etiology ; Calcitriol/therapeutic use ; Calcium/blood ; Calcium Carbonate/therapeutic use ; Calcium Channel Agonists/therapeutic use ; Humans ; Intestine, Small/*radiography ; Kidney Failure, Chronic/therapy ; Male ; Mesenteric Artery, Superior/radiography ; Middle Aged ; Peritoneal Dialysis, Continuous Ambulatory/*adverse effects ; Tomography, X-Ray Computed

A jejunal ectopic pancreas, where pancreatic tissue is found outside of the usual anatomical location, is a rare submucosal tumor that may cause obscure gastrointestinal (GI) bleeding. After initial negative endoscopic evaluation of the obscure GI bleeding, including colonoscopy and/or upper endoscopy, it is reasonable to proceed with further evaluation of the small bowel. Diagnostic options for the evaluation of the small bowel may include capsule endoscopy, push enteroscopy, or barium contrast small bowel studies. Here, we report a case of obscure GI bleeding caused by a jejunal ectopic pancreas, diagnosed through capsule endoscopy and barium contrast small bowel studies, which was treated successfully with single incision access laparoscopy.
Aged ; Capsule Endoscopy ; Diagnosis, Differential ; Female ; Gastrointestinal Hemorrhage/*diagnosis/surgery ; Humans ; Intestine, Small/radiography ; Jejunum/pathology ; Pancreas/pathology

Immunoglobulin G4 (IgG4)-related sclerosing disease is rare and is known to involve various organs. We present a case of histologically proven IgG4-related sclerosing disease of the small bowel with imaging findings on computed tomography (CT) and small bowel series. CT showed irregular wall thickening, loss of mural stratification and aneurysmal dilatation of the distal ileum. Small bowel series showed aneurysmal dilatations, interloop adhesion with traction and abrupt angulation.
Adult ; Antibodies, Anti-Idiotypic/immunology ; Autoimmune Diseases/*diagnosis/immunology ; Humans ; Immunoglobulin G/*immunology ; Intestine, Small/*pathology/radiography ; Male ; Multidetector Computed Tomography/*methods ; Sclerosis/diagnosis/immunology

INTRODUCTIONEnteric fever is a common infection in endemic areas; however, there are few reports describing the computed tomography (CT) manifestations of enteric fever. We aim to describe and illustrate CT findings in enteric fever in this study.

MATERIALS AND METHODSA retrospective search of medical records in our institute for patients with positive blood cultures for Salmonella typhi, and Salmonella paratyphi organisms yielded 39 cases. Among these patients, 12 had undergone a CT study of the abdomen. The CT images, laboratory and clinical findings of these 12 patients were reviewed.

RESULTSThe most common clinical presentation was fever (100%). Typical features of gastroenteritis were present in only over half of the patients. Liver function tests were abnormal in all patients. The most common abdominal manifestations on CT were the presence of mesenteric lymphadenopathy and splenomegaly (75%). Other features were circumferential small bowel wall thickening (58.3%) and free intraperitoneal fluid (50%). Three patients were found to have complications; one with bleeding from terminal ileal ulceration, another with an ileal perforation and the third with renal abscess formation.

CONCLUSIONCT is useful in evaluating enteric fever in patients with severe forms of presentation, a longer clinical course or less specific symptoms. Although the imaging features overlap with other abdominal infections, when combined with clinical features, travel history to endemic areas and presence of transaminitis, the diagnosis of enteric fever should be considered. CT in particular, is useful for the detection of complications such as perforation, bleeding and abscess formation.

Abscess ; diagnostic imaging ; Adolescent ; Adult ; Aged ; Ascitic Fluid ; diagnostic imaging ; Child ; Child, Preschool ; Female ; Humans ; Intestine, Small ; diagnostic imaging ; Lymphatic Diseases ; diagnostic imaging ; Male ; Middle Aged ; Paratyphoid Fever ; diagnostic imaging ; Radiography, Abdominal ; Retrospective Studies ; Salmonella paratyphi A ; Salmonella paratyphi B ; Salmonella typhi ; Splenomegaly ; diagnostic imaging ; Tomography, X-Ray Computed ; Typhoid Fever ; diagnostic imaging

Eosinophilic enteritis is an uncommon disease that rarely manifests as an acute abdomen. A 50-year-old man visited our hospital and complained of epigastric and periumbilical pain. He reported direct and rebound tenderness over the periumbilical area. Laboratory examinations showed leukocytosis without eosinophilia. Plain abdominal radiography revealed air-fluid levels in the small intestine and computed tomography revealed concentric wall thickening in the small bowel and ascites in the pelvic cavity. We conducted an emergency operation and segmental resection of the jejunum was performed. Histologically, transmural, eosinophilic infiltration was observed. In patients with intestinal obstruction, even when presenting with an acute abdomen with no peripheral eosinophilia, eosinophilic enteritis should be included in the differential diagnosis.
Abdomen, Acute ; Ascites ; Diagnosis, Differential ; Emergencies ; Enteritis ; Eosinophilia ; Eosinophils ; Gastritis ; Gastroenteritis ; Humans ; Intestinal Obstruction ; Intestine, Small ; Jejunum ; Leukocytosis ; Middle Aged ; Radiography, Abdominal