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To the Editor:

Imaging studies and serologies are helpful in the diagnosis of small-bowel Crohn's disease (CD); however, they carry a risk of false-positive diagnoses.1, 2 We present a case of obscure overt gastrointestinal bleeding and ileal ulceration with an alternative unifying diagnosis. The patient in this report provided authorization for medical record review for research purposes, and any necessary approval was obtained from the Mayo Clinic Institutional Review Board.

A 60-year-old man had persistent right lower quadrant pain and intermittent maroon stools. He presented to our clinic for management of CD and discussion of biologic therapy. Five years prior to the visit he developed two episodes of brisk hematochezia. The second episode led to hospitalization where his hemoglobin was found to be 8.2 g/dL. He underwent upper endoscopy and ileocolonoscopy where no bleeding source was identified. During the next 4 years he had infrequent maroon stools and right lower quadrant discomfort. Follow-up upper endoscopy, ileocolonoscopy, and tagged red blood scan were normal. Capsule endoscopy suggested ulceration and stricture in the small bowel. Anti-Saccharomyces cerevisiae (ASCA) antibodies were elevated to twice the normal level. The diagnosis of Crohn's ileitis was based on capsule findings and serology results. He was treated with mesalamine and a month of prednisone, and hemoglobin increased to 13 g/dL with a mean corpuscular volume of 85. He presented to our center to discuss alternative treatment strategies for his CD such as biologic therapy.

At our center, computed tomographic enterography (CTE) showed an inflammatory blind-ended stricture near the terminal ileum and no other evidence of small bowel inflammation (Fig. 1). Reevaluation of a previous small bowel barium study revealed the diverticulum near the terminal ileum. Small bowel follow-through did not show signs of CD, and on our reanalysis showed a blind-ended ileal pouch consistent Meckel's diverticulum. CTE also showed blind-ended pouch with signs of ulceration. Meckel's ileitis was a unifying diagnosis which better explained the brisk bleeding and radiographic findings than CD. Subsequent technetium-pertechnetate Meckel's scan was normal; however, its sensitivity is relatively low in the adult population.3 Laparoscopic-assisted small bowel resection revealed a 6-cm Meckel's diverticulum with a broad base which was resected (Fig. 2). Pathology review did not reveal any evidence of CD.

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Figure 1. CT-Enterography: Blind-ended stricture near terminal ileum.

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Figure 2. Surgical specimen: Meckel's diverticulum. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

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Meckel's ileitis is an alternative diagnosis to CD in patients with brisk obscure gastrointestinal bleeding, ulcerations on capsule endoscopy, and abnormal serology tests who lack pathologic evidence of CD. We recommend that alternative etiologies to CD be carefully considered in cases of isolated small bowel ulcerations found on capsule endoscopy given that CD treatments carry significant costs and risks for patients. A safeguard against this uncertainty is to base decisions for initiating immunomodulator and biologic therapy on pathologic examination of the affected bowel.

REFERENCES

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  • 1
    Reese GE, Constantinides VA, Simillis C, et al. Diagnostic precision of anti-Saccharomyces cerevisiae antibodies and perinuclear antineutrophil cytoplasmic antibodies in inflammatory bowel disease. Am J Gastroenterol. 2006; 101: 24102422.
  • 2
    Levesque BG, Cipriano LE, Chang SL, et al. Cost effectiveness of alternative imaging strategies for the diagnosis of small-bowel Crohn's disease. Clin Gastroenterol Hepatol. 2010; 8: 261267, 267 e261–264.
  • 3
    Schwartz MJ, Lewis JH. Meckel's diverticulum: pitfalls in scintigraphic detection in the adult. Am J Gastroenterol. 1984; 79: 611618.

Barrett G. Levesque MD, MS*, Heidi K. Chua MD*, Sunanda V. Kane MD, MSPH*, * Division of Gastroenterology and Hepatology Division of Colon and Rectal Surgery Mayo Clinic, Rochester, Minnesota.