An Unusual Cause of Small Bowel Obstruction

Question: A 37-year-old woman was referred to our Gastroenterology Unit with a 1-month history of crampy abdominal pain associated with poor appetite, nausea, and intermittent vomiting. She reported an approximately 5-kg weight loss during this time. Her background medical history included iron deficiency without anemia and Graves’ disease. She had a history of severe endometriosis, diagnosed 5 years before on a laparoscopy for possible appendicitis. Her endometriosis was untreated apart from a brief trial of the combined oral contraceptive pill, which was stopped due to a negative effect on her mental health. She had undergone repeat laparoscopy 6 weeks earlier due to severe pelvic and lower abdominal pain, after which she made a good initial recovery. The laparoscopy revealed extensive endometriosis on both pelvic side walls, the pouch of Douglas, posterior surface of the uterus, both ovaries, and the right fallopian tube. The appendix and the small bowel appeared normal. The endometriosis was treated with ablative therapy rather than resection. She reported extensive autoimmune diseases in her family including a grandfather with Crohn’s disease, a grandmother with ulcerative colitis, and her mother with Hashimoto’s thyroiditis. A recent blood test demonstrated normal full blood examination, mildly elevated C-reactive protein levels of 6.6 (mg/L) and ferritin of 22 (μg/L). Thyroid-stimulating hormone, urea creatinine and electrolyte, liver function tests, vitamin B12, and celiac serology were normal. Fecal calprotectin was elevated at 765 (μg/g) with no infection detected on fecal microscopy culture and sensitivity or polymerase chain reaction. Computed tomography (CT) of abdomen and pelvis demonstrated thickened loops of distal small bowel with engorgement of the mesenteric vessels in keeping with possible small bowel enteritis (Figure A). Additional magnetic resonance imaging (MRI) of small bowel demonstrated a segment of distal ileal wall thickening to 10 mm with mucosal enhancement (Figure B) and prominent proximal ileal loops of 32 mm consistent with partial bowel obstruction (Figure C). Gastroscopy and ileo-colonoscopy to 5 cm proximal to the ileo-cecal valve showed no evidence of small or large bowel inflammation. Nontargeted ileal and colonic biopsy specimens were normal. A double balloon enteroscopy was attempted for tissue biopsy but was unsuccessful due to the poorly tolerated bowel preparation.