IV.6 Clinical case 6. Bowel obstruction secondary to impacted foreign body and stenosis of the ileocolic anastomosis

 

Bowel obstruction secondary to impacted foreign body and stenosis of the ileocolic anastomosis

Our patient is a 28-year-old male, who was diagnosed with Crohn’s disease, with ileocolic and perianal involvement, at 15 years of age and who developed ileal stenosis that required ileocaecal resection at 26 years.

In his personal history, he reported requiring seasonal treatment with asthma inhalers. He is a non-smoker. He has been on maintenance treatment with azathioprine (2.5 mg/kg/day) since the surgical intervention, and is under periodic follow-up in the Inflammatory Bowel Disease Unit.

The patient is asymptomatic, with occasional episodes of abdominal distension and pain. He maintains his weight and has a normal lifestyle.

Physical examination found no abnormalities and the lab tests performed were within normal ranges, including the C-reactive protein (CRP) and faecal calprotectin levels.

As it had been two years since the surgery, we recommended performing post-surgical monitoring of recurrence via ileocolonoscopy.

 

ILEOCOLONOSCOPY (Video 1)

The examination was performed under sedation with midazolam and fentanyl, reaching the area of the ileocolic anastomosis and observing stenosis of the anastomosis, which did not allow the colonoscope to pass. In the same anastomosis, we observed a broad, extensive ulcer occupying approximately 1/3 of the anastomosis, reaching up to the ileal region, which could not be evaluated correctly.

 

 

Diagnostic approach

Due to the stenosis of the ulcerated anastomosis preventing the colonoscope from passing, the study had to be completed using a radiological imaging technique providing data on the level of inflammation or fibrosis of the stenosis, its extension and the ileal involvement. As this is a young patient and we wanted to limit the radiation dose to be received, we decided to perform a magnetic resonance enterography (MR enterography) study.

 

MAGNETIC RESONANCE ENTEROGRAPHY STUDY (Video 2)

A MR enterography study was performed following the ingestion of a polyethylene glycol solution and the intravenous administration of glucagon and gadolinium.

In this study, we observed limited involvement of the ileocolic anastomosis, extending approximately 5 cm, with wall thickening of approximately 8 mm, predominantly hypointense in relation to a notable fibrotic component; significant stenosis of the intestinal lumen; lack of distensibility, and mild prestenotic dilatation.

 

 

Therapeutic approach

We found stenosis of the anastomosis in a patient operated on for Crohn’s disease. The stenosis could not be passed by the endoscope and was causing episodic symptoms of abdominal pain related to self-limiting sporadic episodes of sub-occlusion.

In the MR enterography study, we adequately evaluated the characteristics of the stenosis: it was a short stenosis, with mixed ulcerated-fibrotic involvement, although the latter predominated. There was no inflammatory involvement of the neo-ileum. The stenosis was significant and led to prestenotic dilatation.

Given the case’s characteristics, we suggested the possibility of endoscopic dilatation to the patient. As the symptoms were not very frequent, the patient preferred to wait and see how his clinical symptoms progressed for the time being.

After approximately three months, the patient had symptoms of abdominal pain that started 1-2 hours after eating, with abdominal distension and a feeling of nausea; he reported the pain as intense and progressive and not stopping with his usual analgesia, so he came into the Emergency Department for evaluation. At that time, the patient was afebrile and normotensive; cardiopulmonary auscultation was normal. The abdomen was soft, with pain on palpation in the right iliac fossa (RIF) and pubic area, with Blumberg’s sign (+). The urgent lab tests performed found moderate leukocytosis with a left shift in the blood count; he had no anaemia and the biochemical parameters tested were normal, except for notable CRP elevation at 120 mg/l.

Urgent abdominal computed tomography (CT) was performed to evaluate complications in a patient with Crohn’s disease and associated stenosis.

 

ABDOMINAL COMPUTED TOMOGRAPHY (Fig. 1)

We performed abdominal CT with IV contrast. It showed parietal thickening and concentric thickening of the ileocolic anastomosis with inflammatory signs, small adjacent extraluminal gas bubbles and an infiltration of the pericaecal fat; these findings are compatible with Crohn’s disease with perforation complications. We also found pneumoperitoneum in the upper portion of the right hemi-abdomen and small locoregional mesenteric adenopathies.

In the ileal region of the anastomosis, we observed a 1.5 cm oval radiopaque foreign body.

 
figura_SEC4_06_F01
 

Therapeutic approach

Given the patient’s clinical condition and the findings of the CT, we decided to perform an urgent surgical intervention on the observed impacted foreign body in the ileal region of the anastomosis, which appeared notably thickened with signs of inflammation. There was notable ileal dilatation with perforation of the anterior face.

We performed a resection of the affected ileocolic region and a mechanical ileocolic latero-lateral anastomosis (Fig. 2).

When we interviewed the patient again, he clearly remembered accidentally ingesting an apricot kernel during the meal preceding the appearance of acute symptoms of abdominal pain.

 
figura_SEC4_06_F02
 

DIAGNOSIS

Episode of bowel obstruction and secondary perforation due to an impacted fruit kernel with stenosis of the ileocolic anastomosis in a patient with Crohn’s disease and previous ileocaecal resection.

 

PROGRESS

The patient progressed appropriately. On discharge, we reintroduced the azathioprine treatment, with follow-up in the Inflammatory Bowel Disease Unit, requiring resin cholestyramine to control the diarrhoea secondary to intestinal resection and the malabsorption of bile salts.

The patient remained asymptomatic, with periodic repeat lab tests within normal ranges. One year after the secondary surgery, we performed a new repeat endoscopy to evaluate post-surgical recurrence.

 

ANNUAL REPEAT ENDOSCOPY (Video 3)

The examination was performed under sedation. The anal and rectal digital examinations found no notable results. We performed a full colonoscopy up to the ileocolic anastomosis, with the following findings:

• In the area of the anastomosis, we observed perianastomotic ulcers.

• The ileal loop was completely permeable and easily examinable: we observed some ileal aphthous ulcers and other small ulcers, in <10% of the total explored area.

• The findings were compatible with grade 2b post-surgical recurrence according to Rutgeerts’ Classification.

 

 

Therapeutic approach

We adjusted the azathioprine dose, based on the patient’s weight, up to a dose of 2.5 mg/kg, as he was slightly undertreated.

In agreement with the patient, we have decided to perform an early new repeat endoscopy after approximately 6 months to 1 year to evaluate the introduction of treatment with anti-TNF drugs, if necessary, as this is an individual with two previous interventions related to the disease and a new post-surgical endoscopic recurrence.

 

SUPPORTING SCIENTIFIC UPDATE

II.5.1. Endoscopic techniques to evaluate post-surgical recurrence

II.5.2. Radiological studies to evaluate post-surgical recurrence

II.6. Seeking consensus between the different diagnostic and follow-up options for inflammatory bowel disease. Interpretation of the results obtained

 

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