CASE REPORT

A 28-years-old man was referred to the gastrointestinal clinic with weight loss over 6 months associated with self-limiting diarrhea, vomiting and poorly localized abdominal pain. There was no significant past medical or family history. Physical examination was unremarkable. Laboratory tests revealed leukopenia (3,16G/L) and mild elevation of transaminases (AST 75 U/L e ALT 118 U/L). The others biochemical indices were normal. The abdominal ultrasound showed a target-shaped lesion representing a small bowel intussusception, bowel edema with increased vascularization and mesenteric lymphadenopathy. Contrast-enhanced computed tomography (CT) confirmed small bowel intussusception from umbilical to the hypogastric region without other CT abnormalities. The culture and parasitological examination of stools, the detection of Clostridium difficile toxin and leukocytes, HIV, Chlamydea, Salmonella and Yersinia serology were negative. Celiac serology panel revealed an IgA tissue transglutaminase (TTG) and an IgG TTG strongly positive. Esophagogastroduodenoscopy not revealed mucosal changes however were performed duodenal biopsies. Histological examination of biopsies revealed intraepithelial lymphocytosis and complete villous atrophy confirming the diagnosis of celiac sprue. The clinical evolution was favourable after gluteen free diet.

Figure 1 I Thickened valvulae conniventes

Figure 2 I Enlarged, rounded, hyperechoic mesentery lymphonode

Figure 3 I Target-shaped lesion representing a small bowel intussusception; Bowel edema and lightly thickened wall (3-5mm)

Discussion:

Celiac disease (CD) is a common disease with small bowel malabsorption that is largely undiagnosed in adults and appears to represent a wide spectrum of clinical features and presentations. Despite the fact, that gold standard for the diagnosis of celiac disease is histologic confirmation of the intestinal damage in serologically positive individuals, in patients with untreated celiac disease we can regularly find out several sonographic signs that raise suspicion of this chronic disease also in clinically asymptomatic persons. Lightly thickened bowel wall (3-5mm), thickened valvulae conniventes, intermittent intussusceptions due hyperperistalsis and presence of slightly enlarged mesenterial lymph nodes are frequently seen in patients with untreated celiac sprue. None of the ultrasound signs identified are specific, but a combination of signs is characteristic and indicates suspicion of this disease.

References:

(1) Bartusek D, Valek V, Husty J, Uteseny J. Small bowel ultrasound in patients with celiac disease Retrospective study. European Journal of Radiology 2007; 63:302–306.

(2) Maconi G, Radice E, Greco S, Bezzio C, Bianchi Porro G. Transient small-bowel intussusceptions in adults: significance of ultrasonographic detection. Clinical Radiology. 2007; 62:792-797.

(3) Kralik R, Trnovsky P, Kopácová M. Transabdominal Ultrassonography of the small bowel. Gastroenterology Research and Practice. 2013; 2013:896704.7611

Authors:

Cátia Leitão, Antonieta Santos, Ana Caldeira, Eduardo Pereira, António Banhudo

Department of Gastroenterology, Hospital Amato Lusitano, Castelo Branco, Portugal