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| CASE REPORT |
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| Year : 2015 | Volume
: 4
| Issue : 1 | Page : 49-53 |
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A rare case of intestinal obstruction mimicking ileocecal tuberculosis: Eosinophilic enteritis
MV Sreeharsha, PB Thrishuli, Ajay Hegde
Department of Surgery, Jagadguru Sri Shivarathreeswara Medical College, Jagadguru Sri Shivarathreeswara University, Mysore, Karnataka, India
| Date of Web Publication | 13-Jan-2015 |
Correspondence Address:
M V Sreeharsha
Department of Surgery, Jagadguru Sri Shivarathreeswara Medical College Hospital, Ramanuja Road, Mysore - 570 004, Karnataka
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/2278-344X.149272
A 52-year-old male presented with complaints of pain abdomen, vomiting, and distention of abdomen since 3 months. He had similar complaints 1 year back and was treated conservatively. He was a known case of pulmonary tuberculosis and completed Category I treatment 3 years back. Abdomen was distended with stepladder pattern of visible peristalsis. Erect X-ray of the abdomen was suggestive of intestinal obstruction. Utrasonography (USG) and computed tomography (CT) scan suggested distal ileocecal thickening-probably ileocecal tuberculosis. A provisional diagnosis of ileocecal tuberculosis causing intestinal obstruction was made and patient was taken up for laparotomy. Laparotomy revealed dilated small bowel loops with distended cecum. Right hemicolectomy was performed. Histopathological Examination (HPE) sent showed features of eosinophilic enteritis a rare cause of intestinal obstruction. Keywords: Abdominal tuberculosis, eosinophilic enteritis, intestinal obstruction
How to cite this article:
Sreeharsha M V, Thrishuli P B, Hegde A. A rare case of intestinal obstruction mimicking ileocecal tuberculosis: Eosinophilic enteritis. Int J Health Allied Sci 2015;4:49-53 |
How to cite this URL:
Sreeharsha M V, Thrishuli P B, Hegde A. A rare case of intestinal obstruction mimicking ileocecal tuberculosis: Eosinophilic enteritis. Int J Health Allied Sci [serial online] 2015 [cited 2023 Mar 31];4:49-53. Available from: https://www.ijhas.in/text.asp?2015/4/1/49/149272 |
| Introduction | |  |
Eosiniphilic enteritis is a rare condition which is characterized by dense infiltration of eosinophils in various parts of the gastrointestinal tract (GIT), most commonly the stomach or proximal small bowel. In our case, the patient presented with acute intestinal obstruction, warranting a laparotomy. Histopathology finding of eosinophilic enteritis was made. Eosinophilic enteritis is a very rare cause of distal (ileocecal) obstruction mimicking ileocecal tuberculosis.
| Case report | | |
History
A 52-year-old male patient presented to the casualty of our hospital with complaints of pain abdomen (3 days), vomiting (3 days), distention of abdomen (3 days), not passed stools since 3 days. He had similar complaints (4 episodes) over a span of 1 year, which was treated conservatively. He was a known case of pulmonary tuberculosis and completed Category I treatment 3 years back. Not a known case of diabetes mellitus, hypertension, and ischemic heart disease (IHD). No previous history of abdominal surgeries. He was a smoker and alcoholic since 20 years.
Examination
General physical examination was normal. Abdominal examination showed distended abdomen, step ladder pattern of visible peristalsis, diffuse tenderness, no guarding, no rigidity, no organomegaly, no palpable mass. Bowel sounds were hurried. Per rectal examination was roomy, with no mass palpable and no blood staining. Respiratory and cardiovascular systems were normal.
Investigations
Blood
Routine blood investigations including liver function tests were within normal limits.
Radiology
Erect X-ray of the abdomen [Figure 1] showed multiple air fluid levels with features suggestive of intestinal obstruction.
Chest X-ray suggestive of fibrosis of right upper lobe of lung with bronchitis and tenting of the right diaphragm, post tuberculosis (TB) sequelae.
Ultrasound abdomen and pelvis showed mild ascitis with enlarged mesenteric lymph nodes suggestive of abdominal tuberculosis. There was no evidence of gut wall thickening/mass lesion.
Colonoscopy [Figure 2] performed a month back in remission suggested nodular leisons and occlusion of the ascending colon. The rest of the large bowel was normal. The cecum could not be visualized. A biopsy from ascending colon suggested colitis with inflammatory changes.
CECT of the abdomen and pelvis done [Figure 3] earlier suggested suspicious bowel wall thickening at the ileocecal junction-ileocaecal TB.
Clinical diagnosis
Recurrent intestinal obstruction secondary to ileoceacal TB.
Treatment
Patient was treated conservatively with nil by mouth, Ryles tube aspiration and intravenous (IV) fluids, but there was no significant improvement in symptoms and signs. Patient was then planned for an exploratory laparotomy.
Procedure
Exploratory laparotomy was performed with a vertical midline incision. No free fluid was found in the abdomen; two feet of the terminal ileum was dilated [Figure 4] with edema and thickening of bowel wall. The appendix was grossly distended filled with fecoliths. The cecum was nodular and distended. The rest of the small bowel appeared normal. Mesenteric lymph nodes were enlarged. A right hemicolectomy with ileo-transverse anastomosis was performed. | Figure 4: Intra-operative findings - demonstrating dilated terminal ileum
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Post-operative recovery
Patient recovered in the post-operative ward with no complications. Patient was started orally on the 3 rd post-operative day; tolerated oral feeds well.
Histopathology
Pathological examination of the resected specimen gave a diagnosis of eosinophilic enteritis with multiple sections of the ileum and cecum showing dense infiltration of eosinophils in the mucosa, sub mucosa, muscularis, and serosa along with few lymphocytes and plasma cells. [Figure 5],[Figure 6],[Figure 7],[Figure 8] and [Figure 9]. Mucosa of the ileum was ulcerated at places. Sections of the appendix at multiple levels showed eosinophilic infiltration in all layers. Sections from lymph nodes showed reactive follicular hyperplasia with dense infiltration by eosinophils. | Figure 5: HPE: H and E, x40 showing small intestinal mucosa with submucosa
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 | Figure 6: HPE: H and E, x40 showing small intestinal mucosa with submucosa
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 | Figure 7: HPE: H and E, x100 showing ulcerated small intestinal mucosa with lymphoid follicle
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 | Figure 8: HPE: H and E, x200 showing intestinal mucosa with numerous eosinophils in lamina propria
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 | Figure 9: HPE: H and E, x400 showing intestinal mucosa with numerous eosinophils in lamina propria
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Absolute eosinophil count
An absolute eosinophil count sent post-operatively was 360 cells/cumm (Normal < 440 cells/cumm)
| Discussion | | |
Eosinophilic gastrointestinal disorders are a broad spectrum of diseases which involve large amounts of infiltration with eosinophils in the various layers of the GIT. This condition was first described by Kaijser in 1937. In 1970, Klein demonstrated that this disorder could be pathologically classified into three major types: Predominant mucosal, predominant muscle layer, and predominant subserosal.
Clinically, it is subclassified into primary and secondary [Table 1]; primary without a cause for the dense infiltration of eosinophils and secondary with an identifiable cause for eosinophilic infiltration. [1] Primary eosinophilic gastroenteritis (EG) is IgA mediated while secondary is associated with a stimulant like the ones mentioned above in the table. Eosinophilic gastroenteritis has been strongly associated with food allergies, and a concomitant atopic diseases or a family history of allergies is elicited in about 70% of cases. [2]
This case of eosinophilic enteritis is a rare case of secondary EG probably induced by rifampicin usage for his treatment of pulmonary tuberculosis. It closely resembled ileocecal tuberculosis in its presentation and imaging. AEC count was normal ruling out Hypereosinophilic syndrome. No intestinal heliminths were found on subsequent stool examinations. Pubmed search of eosinophilic colitis yielded only one other case reported by P. Lange et al., [3] making this an extremely rare case of rifampicin-induced eosinophilic enterocolitis.
Eosinophilic enterocolitis can present with varied signs and symptoms of GI abnormalities like pain abdomen, weight loss, malabsorption syndromes, diarrhea, ascites, intestinal obstruction, perforation. The signs and symptoms vary depending upon the degree of infiltration of eosinophils. The disease may be diffuse or segmental in nature. Mucosa predominant disorder is associated with mucosal injury and presents with malabsorption, diarrhea, and protein-losing enteropathy. Transmural disease presents with colonic wall thickening and features of intestinal obstruction. [4] Transmural infiltration of the ileum and cecum with eosinophils in our case explains the intestinal obstruction.
Colonocopy may reveal edematous mucosa with a loss of the normal vascular pattern, patchy erythematous changes, and even superficial ulcerations like in inflammatory bowel disease. Treatment of secondary eosinophilic enteritis like our case is primarily with removal of the stimulating factor which includes deworming with Albendazole 400mg and discontinuation of drugs like rifampicin. Glucocorticoids also play an important role in the management of diffuse and mild disease. Steroids inhibit eosinophil growth factors like interleukin-3 (IL-3), interleukin-5 (IL-5), and granulocyte-macrophage colony-stimulating factor (GM-CSF). Prednisolone at doses of 1-2 mg/kg body weight for 8 weeks tapered over 8-10 weeks improve both clinical and pathological findings in cases. Relapses may require a long term low dose corticosteroid therapy. Immunomodulators like Azathioprine down-regulate chemokines such as eotaxin which are involved in eosinophilic recruitment. A combination of glucocorticosteroids and azathioprine can decrease the tissue eosinophilia and improve the diarrhea at least in EG. [5],[6]
This patient presented with multiple episodes of intestinal obstruction with multiple admission is various centers, hence we went ahead with a limited right hemicolectomy and ileo-transverse anastomosis. Patient was post-operatively started on steroids for 6 months and followed up for a year with no signs of relapse.
| Conclusion | | |
There are various causes for intestinal obstruction and ileocecal tuberculosis is one of the commonest cause of distal ileal obstruction in India. Eosinophilic enteritis is a rare cause of intestinal obstruction with varied etiology which can mimic ileocecal tuberculosis. Diagnosis of eosinophilic enteritis requires high degree of suspicion and most often than not diagnosed only with histopathological examination. Differentiation between ileocecal tuberculosis and eosinophilic enteritis becomes more so important in cases not presenting with complete intestinal obstruction in whom conservative treatment would be planned; as the treatment option is entirely different. In our case since the patient presented with intestinal obstruction, the initial surgical management did not differ and the histopathological report helped in proper treatment option in the post-operative period. There are not much cases of eosinophilic enteritis presenting with intestinal obstruction reported in the literature and hence we are presenting this case report.
| References | | |
| 1. | Klein NC, Hargrove RL, Sleisenger MH, Jeffries GH. Eosinophilic gastroenteritis. Medicine (Baltimore) 1970;49:299-319.  [ PUBMED] |
| 2. | Khan S, Orenstein SR. Eosinophilic gastroenteritis: Epidemiology, diagnosis and management. Paediatr Drugs 2002;4:563-70. |
| 3. | Lange P, Oun H, Fuller S, Turney JH. Eosinophilic colitis due to rifampicin. Lancet 1994;344:1296-7. [ PUBMED] |
| 4. | Alfadda AA, Storr MA, Shaffer EA. Eosinophilic colitis: Epidemiology, clinical features, and current management. Therap Adv Gastroenterol 2011;4:301-9. |
| 5. | Copeland B, Aramide OO, Wehbe SA, Fitzgerald SM, Krishnaswamy G. Eosinophilia in a patient with cyclical vomiting: A case report. Clin Mol Allergy 2004;2:7. |
| 6. | Clouse RE, Alpers DH, Hockenbery DM, DeSchryver-Kecskemeti K. Pericrypt eosinophilic enterocolitis and chronic diarrhea. Gastroenterology 1992;103:168-76. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
[Table 1]
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