PICTURES IN DIGESTIVE PATHOLOGY

 

Intestinal intussusception as an atypical presentation of celiac disease

Invaginación intestinal como presentación atípica de enfermedad celiaca

 

 

Enrique Pérez-Cuadrado-Robles, Paloma Bebia-Conesa, Blanca Martínez-Andrés, Pilar Esteban-Delgado, Antonio López-Higueras and Enrique Pérez-Cuadrado-Martínez

Department of Digestive Diseases. Small Bowel Unit. Hospital Universitario Morales Meseguer. Murcia, Spain

 

 

Case report

A 31-year-old woman was studied because of chronic ferropenic anemia and colicky abdominal pain for many years. An upper gastrointestinal endoscopy was performed that revealed no mucosal changes, with a normal villous pattern and normal duodenal biopsy. Colonoscopy yielded no findings. A CT scan revealed a thickened jejunal wall with mesenteric adenopathies and no evidence of intestinal ischemia or obstruction. Capsule endoscopy (CE) was indicated, which revealed from the proximal jejunum the characteristic, diffusely cracked mucosa of celiac disease (CD), with atrophy and a mosaic pattern (Fig. 1A). A jejuno-jejunal invagination was identified in the distal jejunum (Fig. 1B) with a transition of normal mucosa over the involved mucosa that might correspond to the image shown by CT. CE showed a preserved villous pattern in the distal small bowel. A subsequent double-balloon enteroscopy with histopathologic study confirmed the presence of patchy CD in the proximal jejunum.

 

 

Discussion

CE is indicated for suspected atypical or patchy CD, where duodenal biopsy may obtain a false negative result (1,2). Furthermore, in established CD, CE may be useful to monitor mucosal healing, or in refractory cases to screen potential accompanying complications (ulcerative jejunitis, lymphoma) (3).

The cause of recurrent colicky pain in CD remains unclear. However, the invagination of the atrophic proximal mucosa into the normal distal (thicker) mucosa has been suggested to account for this manifestation.

Transient intestinal intussusception is a rare complication of CD more commonly seen in children (4). In the adult, organic disease (neoplasms) must be ruled out, but in a proper clinical setting intussusception may be highly suggestive of CD. In our patient, CE allowed a diagnosis of suspected CD and ruled out other, potentially more severe causes of invagination.

 

References

1. Kurien M, Evans KE, Aziz I, et al. Capsule endoscopy in adult celiac disease: A potential role in equivocal cases of celiac disease? Gastrointest Endosc 2013;77:227-32.         [ Links ]

2. Rostami-Nejad M, Villanacci V, Hogg-Kollars S, et al. Endoscopic and histological pitfalls in the diagnosis of celiac disease: A multicentre study assessing the current practice. Rev Esp Enferm Dig 2013;105:326-33.         [ Links ]

3. Spada C, Riccioni ME, Urgesi R, et al. Capsule endoscopy in celiac disease. World J Gastroenterol 2008;14:4146-51.         [ Links ]

4. Ludvigsson JF, Nordenskjöld A, Murray JA, et al. A large nationwide population-based case-control study of the association between intussusception and later celiac disease. BMC Gastroenterol 2013;16:89.         [ Links ]