Isolated visceral manifestation of Buerger's disease presenting as intestinal obstruction: a case report

Abstract

Introduction and importance: Buerger's disease is an uncommon segmental nonatherosclerotic vasculitis essentially affecting small to medium-sized arteries and veins of upper and lower extremities and can lead to limb amputation. Visceral vessel involvement is quite rare accounting for 2% of cases presenting with acute abdomen due to mesenteric ischemia. Moreover, isolated visceral involvement is even rare.

Case presentation: A 42-year-old gentleman, a chronic smoker, presented with abdominal pain associated with nausea and vomiting and loose stool of 2 months duration. Magnetic resonance enterography revealed segmental circumferential wall thickening with stricture in the mid part of the jejunum with lymphadenopathy features of possible inflammatory bowel disease (Crohn's disease). Furthermore, intraoperative surgical findings were also suggestive of Crohn's disease. However, histologic findings were consistent with thromboangiitis obliterans.

Discussion: Thromboangiitis obliterans can present with inflammatory vascular lesions without necrosis in the early stage to varying degrees of recanalisation, gangrene, and amputation in the late stage. It rarely involves the brain, heart, and abdominal viscera. The visceral involvement may be in the form of intestinal obstruction or mesenteric ischemia or can mimic Crohn's in a background of smoking.

Conclusion: This case report will help to learn more about the rarer intestinal presentation of intestinal Buerger's disease. It can present with features of bowel ischemia, obstruction or Crohn's. So, histology would play a pivotal role in differentiating the diagnostic dilemma.

Keywords: Buerger’s disease; case report; ischemia; thromboangiitis obliterans; visceral complications.

Figure 1

A, B, C: Magnetic resonance enterography showing circumferential wall thickening with a stricture of mid jejunum with proximal dilatation of the lumen. D: magnetic resonance angiography showing few beaded appearances of the distal superior mesenteric arterial branches without occlusion and with the normal celiac trunk, proximal superior mesenteric artery, and inferior mesenteric artery.

Figure 2

A, B, C: Histopathological picture showing the foci of ulcerative mucosa with acute and chronic inflammation, hemorrhage and necrosis. Arterioles showing intimal thickening with edema and fibrosis and many with near occlusion, rare small vessel inflammation.