PMC6394366_01
Double-contrast barium enema of the colon showing inflammation of the ascending colon and the cecum. The bowel is narrowed at the lower portion of the ascending colon. Cobblestone appearance is seen in the upper portion of the ascending colon. Fissurings are indicated by arrows.
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The initial diagnostic workup revealed the cobblestone appearance of the mucosa and fissurings in the right colon (Figure 1), leading to a diagnosis of CD.
Plain abdominal radiographs on admission (A) and 13 days after the first infusion of infliximab (B). Solitary air-fluid level is indicated by an arrow (A). Multiple air-fluid levels are seen (B); C
- Picture of the enteroclysis. Two stenotic portions are observed in the distal part of the ileum (white arrows). At the sites of stenosis, white soft shadows are seen (hollowed arrows) indicating active ulcers. Pre-stenotic dilatation is not observed. Longitudinal ulcers are observed (arrowheads).
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Plain film of the abdomen showed an isolated air-fluid level (Figure 2A), but he did not have symptoms indicating an intestinal obstruction. Enteroclysis revealed stenotic portions and longitudinal ulcers in the distal portion of the ileum (Figure 2C). Intestinal obstruction was diagnosed due to clear air-fluid levels on plain abdominal radiographs (Figure 2B).
Gross examination of the resected specimen of case 1. Two round ulcers at the proximal site (arrowheads) and a longitudinal ulcer of 30 cm (arrows) are seen in the terminal ileum. Cobblestone appearance is seen in the ascending colon. The appendix (Ap) is swollen.
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The resected specimen showed round ulcers at the proximal site and a longitudinal ulcer of approximately 30 cm (Figure 3).
PMC6394366_02
Double-contrast barium enema study. Entire picture of the colon (A) and enlarged picture of the ileocolic portion (B). A - Shortening of the right colon is seen. Diffuse coarse mucosa from the sigmoid colon to the distal part of the descending colon is observed. B - Two stenotic sites in the terminal ileum are indicated by white arrows. There are two entero-enteric fistulas indicated by F. TC, transverse colon; AC, ascending colon; TI, terminal ileum; F, fistula.
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Barium enema study revealed shortening of the right colon, stenotic sites, fistulas in the terminal ileum (Figure 4), and a diffuse coarse mucosa from the sigmoid to the distal part of the descending colon (Figure 4A). Plain film of the abdomen was unremarkable, however, enteroclysis revealed entero-enteric fistulas and stenotic sites in the distal ileum (Figure 4B).
Plain abdominal radiographs on the 11th day after the first infusion of infliximab (A) and the day following resumption of meals after the 3rd infliximab infusion (B). Air-fluid levels are indicated by arrows (A).
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Radiographic signs of intestinal obstruction were found (Figure 5A), and meals were withdrawn. Resumption of meals (800 kcal/day) resulted in repetition of abdominal distension and air-fluid level on the following day (Figure 5B).
Gross examination of the resected specimen of the case 2. The terminal ileum is fixed to the ascending colon by adhesion through fistulas. They were removed en bloc. Arrows indicate longitudinal ulcers (scar).
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The resected specimen showed longitudinal ulcers in the ileum and colon (Figure 6).