Letters to the Editor
Harvard Medical School, Boston, Massachusetts, USA. Correspondence: Joseph Feuerstein, MD, Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue E/Dana 501, Boston, Massachusetts 02215, USA. E-mail: [email protected]
Terminal Ileitis Found Upon Imaging: Is It Always Crohn’s Disease? Teresa Pinto Pais, MD1, Sónia Fernandes, MD1, Carlos Fernandes, MD1, Iolanda Ribeiro, MD1 and João Carvalho, MD1 doi:10.1038/ajg.2014.114
To the Editor: Terminal ileitis (TI), defined as inflammation of the terminal ileum, is a common condition in clinical practice and is classically associated with Crohn’s disease (CD). However, a wide variety of diseases may be associated with ileitis (1,2). Diagnosis of the specific cause of ileitis is of paramount importance because misdiagnosis may result in critical delays or errors in patient management (3–5). Nonetheless, distinguishing between the various forms of ileitis remains a test of clinical acumen. Accurate diagnosis is suggested by a detailed history and physical examination, by laboratory testing, and by ileocolonoscopy and/or radiological evaluation. To study the different entities associated with TI in clinical practice, we reviewed all patients with confirmed imaging of TI on ultrasound admitted to our department over four consecutive years. An observational, descriptive, longitudinal study was performed, with a retrospective review of demographics, clinical presentation, laboratory data, treatment, and follow-up. Abdominal ultrasonography was performed in all patients and was complemented with computed tomography when necessary. Sonographic features compatible with TI included hypoechogenic mural thickening of the terminal ileum and hypoechoic enlarged mesenteric lymph nodes (6). The diagnosis of ileal CD was based on clinical, endoscopic, and histopathological data. Acid-fast bacilli smear and culture © 2014 by the American College of Gastroenterology
were performed in ileal biopsy specimens. An infectious etiology was presumed when there was clinical, analytical, and imaging remission after empirical antibiotic therapy, or when confirmed by isolation of pathogenic microorganisms in stool cultures. This study assessed 62 patients with a median age of 38.2 years (18–82), with a slight predominance of females (56.4%). The main form of presentation was abdominal pain (93.5%) and diarrhea (67.7%). All patients presented with ultrasonographic features of TI, which were corroborated by computed tomography in 62.9%. In this study, infectious etiology was confirmed in 62.9% (n = 39) of patients, CD was diagnosed in 32.2% (n = 20), and ileum cancer in 4.9% (ileal lymphoma—2, adenocarcinoma—1). Fecal pathogens were identified in 7 patients: Campylobacter—3, Yersinia—2, and Salmonella—2. No parasitic or tuberculosis infection was identified. On comparing the groups with confirmed CD and infectious ileitis, we found in the first group higher median values of serum inflammatory parameters (C-reactive protein: 9.8 vs. 7.4 mg/dl; leukocyte count: 16.650 vs. 11.170/μl), lower hemoglobin levels (10.45 vs. 13.5 g/dl, t-test, P=0.03), and a longer inpatient period (10 vs. 5 days). Patients diagnosed with CD maintain longterm follow-up in our outpatient clinic. In the current study, the diagnosis of CD of the ileum was confirmed histopathologically in 32.2% of patients with imaging of TI. We highlight that inflammation of the terminal ileum is not always CD, and infectious etiology is a common cause (62.9% in our study). The differential diagnosis of TI found on imaging, although sometimes difficult, is of critical importance to avoid further unnecessary diagnostic workup and inappropriate treatment. CONFLICT OF INTEREST Guarantor of the article: Teresa Pinto Pais, MD. Specific author contributions: Teresa Pinto Pais was involved in planning and conducting the study, collecting and interpreting data, and writing the paper. She has approved the final draft submitted. Sónia Fernandes was involved in planning the study, interpreting data, and drafting the
manuscript. She has approved the final draft submitted. Carlos Fernandes was involved in collecting and interpreting data. He has approved the final draft submitted. Iolanda Ribeiro was involved in collecting and interpreting data. She has approved the final draft submitted. João Carvalho was involved in planning the study, interpreting data, and drafting the manuscript. He has approved the final draft submitted. Financial support: None. Potential competing interests: None.
REFERENCES 1. Dilauro S, Crum-Cianflone NF. Ileitis: when it is not Crohn’s disease. Curr Gastroenterol Rep 2010;12:249–58. 2. Greaves ML, Pochapin M. Asymptomatic ileitis: past, present, and future. J Clin Gastroenterol 2006;40:281–5. 3. Lee YJ, Yang SK, Byeon JS et al. Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohn’s disease. Endoscopy 2006;38:592–7. 4. Jeong SH, Lee KJ, Kim YB et al. Diagnostic value of terminal ileum intubation during colonoscopy. J Gastroenterol Hepatol 2008;23:51–5. 5. Chang HS, Lee D, Kim JC et al. Isolated terminal ileal ulcerations in asymptomatic individuals: natural course and clinical significance. Gastrointest Endosc 2010;72:1226–32. 6. Ledermann HP, Börner N, Strunk H et al. Bowel wall thickening on transabdominal sonography. Am J Roentgenol 2000;174:107–17. 1
Department of Gastroenterology and Hepatology, Centro Hospitalar de Gaia/Espinho, Vila Nova de Gaia, Portugal. Correspondence: Teresa Pinto Pais, MD, Department of Gastroenterology and Hepatology, Centro Hospitalar de Gaia/Espinho, Rua Conceição Fernandes, 4434-502 Vila Nova de Gaia, Portugal. E-mail: [email protected]
Patient Satisfaction Does Not Correlate With Established Colonoscopy Quality Metrics Rena Yadlapati, MD1, Andrew Gawron, MD1,2 and Rajesh N. Keswani, MD1 doi:10.1038/ajg.2014.115
To the Editor: Quality metrics for colonoscopy are increasingly being measured and reported, as procedure quality correlates The American Journal of GASTROENTEROLOGY
1089
Harvard Medical School, Boston, Massachusetts, USA. Correspondence: Joseph Feuerstein, MD, Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue E/Dana 501, Boston, Massachusetts 02215, USA. E-mail: [email protected]
Terminal Ileitis Found Upon Imaging: Is It Always Crohn’s Disease? Teresa Pinto Pais, MD1, Sónia Fernandes, MD1, Carlos Fernandes, MD1, Iolanda Ribeiro, MD1 and João Carvalho, MD1 doi:10.1038/ajg.2014.114
To the Editor: Terminal ileitis (TI), defined as inflammation of the terminal ileum, is a common condition in clinical practice and is classically associated with Crohn’s disease (CD). However, a wide variety of diseases may be associated with ileitis (1,2). Diagnosis of the specific cause of ileitis is of paramount importance because misdiagnosis may result in critical delays or errors in patient management (3–5). Nonetheless, distinguishing between the various forms of ileitis remains a test of clinical acumen. Accurate diagnosis is suggested by a detailed history and physical examination, by laboratory testing, and by ileocolonoscopy and/or radiological evaluation. To study the different entities associated with TI in clinical practice, we reviewed all patients with confirmed imaging of TI on ultrasound admitted to our department over four consecutive years. An observational, descriptive, longitudinal study was performed, with a retrospective review of demographics, clinical presentation, laboratory data, treatment, and follow-up. Abdominal ultrasonography was performed in all patients and was complemented with computed tomography when necessary. Sonographic features compatible with TI included hypoechogenic mural thickening of the terminal ileum and hypoechoic enlarged mesenteric lymph nodes (6). The diagnosis of ileal CD was based on clinical, endoscopic, and histopathological data. Acid-fast bacilli smear and culture © 2014 by the American College of Gastroenterology
were performed in ileal biopsy specimens. An infectious etiology was presumed when there was clinical, analytical, and imaging remission after empirical antibiotic therapy, or when confirmed by isolation of pathogenic microorganisms in stool cultures. This study assessed 62 patients with a median age of 38.2 years (18–82), with a slight predominance of females (56.4%). The main form of presentation was abdominal pain (93.5%) and diarrhea (67.7%). All patients presented with ultrasonographic features of TI, which were corroborated by computed tomography in 62.9%. In this study, infectious etiology was confirmed in 62.9% (n = 39) of patients, CD was diagnosed in 32.2% (n = 20), and ileum cancer in 4.9% (ileal lymphoma—2, adenocarcinoma—1). Fecal pathogens were identified in 7 patients: Campylobacter—3, Yersinia—2, and Salmonella—2. No parasitic or tuberculosis infection was identified. On comparing the groups with confirmed CD and infectious ileitis, we found in the first group higher median values of serum inflammatory parameters (C-reactive protein: 9.8 vs. 7.4 mg/dl; leukocyte count: 16.650 vs. 11.170/μl), lower hemoglobin levels (10.45 vs. 13.5 g/dl, t-test, P=0.03), and a longer inpatient period (10 vs. 5 days). Patients diagnosed with CD maintain longterm follow-up in our outpatient clinic. In the current study, the diagnosis of CD of the ileum was confirmed histopathologically in 32.2% of patients with imaging of TI. We highlight that inflammation of the terminal ileum is not always CD, and infectious etiology is a common cause (62.9% in our study). The differential diagnosis of TI found on imaging, although sometimes difficult, is of critical importance to avoid further unnecessary diagnostic workup and inappropriate treatment. CONFLICT OF INTEREST Guarantor of the article: Teresa Pinto Pais, MD. Specific author contributions: Teresa Pinto Pais was involved in planning and conducting the study, collecting and interpreting data, and writing the paper. She has approved the final draft submitted. Sónia Fernandes was involved in planning the study, interpreting data, and drafting the
manuscript. She has approved the final draft submitted. Carlos Fernandes was involved in collecting and interpreting data. He has approved the final draft submitted. Iolanda Ribeiro was involved in collecting and interpreting data. She has approved the final draft submitted. João Carvalho was involved in planning the study, interpreting data, and drafting the manuscript. He has approved the final draft submitted. Financial support: None. Potential competing interests: None.
REFERENCES 1. Dilauro S, Crum-Cianflone NF. Ileitis: when it is not Crohn’s disease. Curr Gastroenterol Rep 2010;12:249–58. 2. Greaves ML, Pochapin M. Asymptomatic ileitis: past, present, and future. J Clin Gastroenterol 2006;40:281–5. 3. Lee YJ, Yang SK, Byeon JS et al. Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohn’s disease. Endoscopy 2006;38:592–7. 4. Jeong SH, Lee KJ, Kim YB et al. Diagnostic value of terminal ileum intubation during colonoscopy. J Gastroenterol Hepatol 2008;23:51–5. 5. Chang HS, Lee D, Kim JC et al. Isolated terminal ileal ulcerations in asymptomatic individuals: natural course and clinical significance. Gastrointest Endosc 2010;72:1226–32. 6. Ledermann HP, Börner N, Strunk H et al. Bowel wall thickening on transabdominal sonography. Am J Roentgenol 2000;174:107–17. 1
Department of Gastroenterology and Hepatology, Centro Hospitalar de Gaia/Espinho, Vila Nova de Gaia, Portugal. Correspondence: Teresa Pinto Pais, MD, Department of Gastroenterology and Hepatology, Centro Hospitalar de Gaia/Espinho, Rua Conceição Fernandes, 4434-502 Vila Nova de Gaia, Portugal. E-mail: [email protected]
Patient Satisfaction Does Not Correlate With Established Colonoscopy Quality Metrics Rena Yadlapati, MD1, Andrew Gawron, MD1,2 and Rajesh N. Keswani, MD1 doi:10.1038/ajg.2014.115
To the Editor: Quality metrics for colonoscopy are increasingly being measured and reported, as procedure quality correlates The American Journal of GASTROENTEROLOGY
1089
