Small intestinal obstruction resulting from ischemic enteritis: a case report
A 69-year-old male was admitted to our institution because of a sudden onset of vomiting and abdominal distention in April 2012. His general history did not include smoking or alcohol consumption; however, his medical history included a femoral head fracture, which was treated with an artificial femoral head when he was 60 years old, and congestive heart failure, which improved with diuretic administration in November 2011.\nHis past history also included an episode of ischaemic colitis which presented with severe left-sided abdominal pain. Abdominal radiography and computed tomography revealed no abnormal findings, although colonoscopy revealed longitudinal ulcers in the descending colon (Fig. a). These findings led to a diagnosis of ischaemic colitis. Capsule endoscopy revealed circumferential ulcers in the distal small intestine (Fig. b) and single-balloon enteroscopy confirmed the same in the distal ileum (Fig. c). Ischaemic enteritis was suspected and the patient was prescribed a treatment that included fasting and blood transfusion. Thereafter, his symptom improved rapidly.\nOn admission, the patient’s blood pressure was 103/54 mmHg, heart rate was 72 beats/min, body temperature was 36.3 °C and oxygen saturation was 97 % in room air. On clinical examination, his weight was 51 kg, height was 166 cm and body mass index was 18.5 kg/m2. Inspection of the palpebral conjunctiva revealed evidence of mild anaemia, whereas a chest auscultation revealed no abnormal findings and physical examination revealed no oedema or cyanosis. The patient’s abdomen was markedly distended and reduced peristalsis was evident with mild tenderness over abdominal region. There were no palpable masses or signs of peritoneal irritation.\nBlood chemistry revealed a normal white blood cell count (7000 cells/μL), mild anaemia (red blood cell count, 321 × 104/μL; haemoglobin, 9.2 g/dL), elevated C-reactive protein level (4.8 mg/dL), mild hypoproteinaemia (5.5 g/dL), mild hypoalbuminaemia (2.4 g/dL), mildly elevated serum creatine level (1.36 mg/dL), mildly elevated blood urea nitrogen level (25.6 mg/dL), hyponatraemia (128 mEq/L) and an elevated glucose level (144 mg/dL; Table ). Tuberculin and several stool culture tests were negative. On admission, plain abdominal radiography revealed dilated small intestinal loops (Fig. a). Plain abdominal computed tomography revealed extensively dilated small intestinal loops, a calibre change around the ileal end and an absence of ascites (Fig. b, c). Therefore, small intestinal obstruction was diagnosed and a transnasal ileus tube was placed (Fig. a). During decompression of the small intestinal obstruction using the ileus tube, the patient was fasting and was treated with total parenteral nutrition. The ileus tube was progressively moved along the small intestine until it reached the distal ileum on post-admission day 4. The injected contrast medium revealed a stricture in the distal ileum (Fig. b). Transanal single-balloon enteroscopy performed to inspect the stricture revealed a circumferential and afferent tubular ulcer in the distal ileum, 5 cm from the ileocecal valve (Fig. a); gastrofluorography confirmed the stricture (Fig. b), which was dilated using balloon catheters on several occasions but could not be improved.\nDespite treatment, the patient’s nutritional status deteriorated and his anaemia progressed, with the latter necessitating a blood transfusion. Consequently, we decided to perform surgery on post-admission day 37.\nOperative findings revealed several strictures in the distal ileum (Fig. a). In total, 42 cm of the ileum, including the known stricture, was resected. Several circumferential ulcers with clear margins were detected in the ileum at 5–28 cm from the ileocecal valve (Fig. b). Histological findings revealed the following (Fig. a–c): stenotic portions of the ileum formed ulcers of grade Ul-II with an intact muscularis mucosa, the ileal lumen was covered with fibrin and fibrous connective tissue, an inflammatory cell infiltrate was present in all layers, particularly lymphocytes and eosinophils, dilatation and congestion of capillary vessels was observed in the submucosa and haemosiderin staining revealed sideroferous cells in the submucosal layers. Considering these findings, ischaemic enteritis was confirmed in the resected specimen.\nThe patient’s post-operative course was uneventful. Oral intake was initiated and the patient experienced no recurrence of small intestinal obstruction or symptom of abdominal pain.