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An unexpected cause of terminal ileitis

Published:October 08, 2016DOI:https://doi.org/10.1016/j.gie.2016.10.001
      A 20-year-old woman with Crohn’s disease (CD) who had a positive family history of CD was referred to our hospital because of therapy-refractory CD, which had been diagnosed 2 years before referral. The initial diagnosis was made on the basis of clinical presentation and the results of ileocolonoscopy, which showed erosions in the terminal ileum. Pathologic examination of these lesions showed chronic inflammation without granulomas. At the time of referral, she had been treated with budesonide 9 mg once daily for more than a year. Shortly after the first outpatient visit at our hospital, she was admitted with generalized abdominal pain, vomiting, and bloody stools. Laboratory determinations of inflammation showed no abnormalities, and fecal cultures were negative. Ileocolonoscopy showed erosions in the terminal ileum. To evaluate for stenosis, computed tomographic enterography was performed and 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, distal enteroscopy with a double-balloon endoscope (Fujifilm EN-580T) was performed for both diagnosis and possible endoscopic dilatation of the stenosis. Surprisingly, enteroscopy revealed a diverticulum 60 cm proximal to the ileocecal valve with a mucosal bridge, a nummular lesion within the diverticulum, and small erosions surrounding the diverticulum (Video 1, available online at www.giejournal.org). Furthermore, enteroscopy showed erosions and an ulcer in the ileum distal to the diverticulum, without stenosis. Biopsy specimens of the nummular lesion in the diverticula showed chronic inflammation and heterotopic remains of gastric mucosa (Fig. 1). A diagnosis of Meckel’s diverticulum was made. After surgical resection of the diverticulum, the patient was asymptomatic.
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      Figure 1Histopathologic view of the nummular lesion within the ileal diverticulum showing gastric glands (arrows) containing typical gastric oxyntic chief cells. There is a little inflammation in the lamina propria (H&E, orig. mag. ×200).
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