A case of severe protein-losing enteropathy as a late complication of pelvic irradiation

Abstract

Protein-losing enteropathy is the manifestation of a diverse set of disorders, and it is characterized by the excessive loss of plasma proteins into the affected portions of the gastrointestinal tract, and this results in hypoalbuminemia. We report here on a case of severe protein-losing enteropathy with the typical clinical features of hypoalbuminemia, dependent edema and increased alpha 1-antitrypsin (alpha1-AT) clearance, as measured by using 24 hr stool testing. The associated disorder with the protein-losing enteropathy of our case was radiation enterocolitis and lymphatic obstruction that was due to radiation treatment and lymph node dissection in the remote past for the treatment of uterine cervical carcinoma. Our case suggests that chronic radiation enterocolitis can result in irreversible injury to the intestinal mucosa and a protein-losing enteropathy, which can bring about a very poor quality of life and even the loss of life.

Figure 1.

Small bowel series shows multifocal luminal narrowing with thumb-printing appearance of lesions (empty arrow) in the ileum.

Figure 2.

Barium enema shows diffuse luminal narrowing with the loss of haustral markings (empty arrow) in the rectum and sigmoid colon.

Figure 3.

Histological findings showing the delayed change of radiation- induced colitis (colonoscopic biopsy) (A) Low-power magnification shows mucosal fibrosis (black arrows) and thickening of muscularis mucosa with irregular arrangement of muscle fibers (H&E, ×100). (B), (C) The mucosa shows increased collagen, atypical fibroblasts (small arrows) and collections of foam cells (arrow heads and inset) of the lamina propria, and atrophic glands with goblet cell depletion (H&E, ×400). (D) High-power magnification of the submucosa reveals atypical cellular change of stromal fibroblasts (small arrows), increased and dilated capillaries with atypical endothelial cells, and the edematous stroma containing lymphocytes and eosinophils (H&E, ×400).

Figure 4.

(A) ^99mTc-human serum albumin scintigraphy shows localized radioactivity in the upper ascending colon on the delay image. (B) ^99mTc-human dextran lymphoscintigraphy reveals the decreased uptake in the left ileac lymph nodes with delayed migration and collateral circulations, suggesting lymphatic obstruction.