Crohn's disease complicated by multiple stenoses and internal fistulas clinically mimicking small bowel endometriosis

Abstract

We report a 31-year-old woman with Crohn's disease complicated by multiple stenoses and internal fistulas clinically misdiagnosed as small bowel endometriosis, due to the patient's perimenstrual symptoms of mechanical subileus for 3 years; at first monthly, but later continuous, and gradually increasing in severity. We performed an exploratory laparotomy for small bowel obstruction, and found multiple ileal strictures and internal enteric fistulas. Because intraoperative findings were thought to indicate Crohn's disease, a right hemicolectomy and partial distal ileum resection were performed for obstructive Crohn's ileitis. Histopathology of the resected specimen revealed Crohn's disease without endometrial tissue. The patient made an uneventful recovery from this procedure and was discharged home 10 d post-operatively. The differential diagnosis of Crohn's disease with intestinal endometriosis may be difficult pre-operatively. The two entities share many overlapping clinical, radiological and pathological features. Nevertheless, when it is difficult to identify the cause of intestinal obstruction in a woman of child-bearing age with cyclical symptoms suggestive of small bowel endometriosis, Crohn's disease should be included in the differential diagnosis.

Figure 1

Contrast-enhanced scan showing the mural thickening of terminal ileum (arrows) (A), and a complex, predominantly inflammatory mass of large size (6.4 cm × 6.1 cm) (arrows) (B).

Figure 2

Gross appearance of the resected specimen showing Crohn’s ileitis with multiple fistulas probed with instruments (A), and ileal segment with two adjacent openings of an internal enteric fistula after separation of adhesions (B).

Figure 3

Microscopic examination of the resected specimen revealed transmural inflammatory cell infiltration with crypt distortion (A), and transmural lymphoid aggregates (B) (HE, A × 10, B × 20).