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From question on page 616

Figure 1 reveals ulcerated and strictured mucosa with a sharp cut off between the normal and abnormal ileum. While these appearances could be seen with intestinal tuberculosis, Crohn’s disease, or lymphoma, the sharp demarcation between the normal and abnormal mucosa suggested a vascular aetiology (that is, intestinal ischaemia).

Biopsies from the ulcerated ileum revealed almost total necrosis of the mucosa with only the crypt bases surviving (fig 2A); this pattern is typical of ischaemic injury. Biopsies from the erythematous proximal region (fig 2B) revealed regenerative mucosa. There was no evidence of malignancy or granulomatous inflammation in any of the biopsies.

Figure 2

 (A) Biopsy from the ulcerated ileum. (B) Biopsy from the erythematous proximal region. (C) Computed tomography angiogram revealing occlusion of the coeliac axis (arrow) and superior mesenteric artery at their origin.

Computed tomographic angiogram (fig 2C) revealed occlusion of the coeliac axis (arrow fig 2C) and superior mesenteric artery (SMA) at their origin.

Forty eight hours after a failed attempt at percutaneous vascular intervention, the patient developed more severe abdominal pain and absent bowel sounds. At emergency laparotomy, blood flow to the proximal small bowel and colon appeared compromised but the distal small bowel was infarcted. A 70 cm region of terminal ileum was resected and the SMA stented in a retrograde fashion.

Following a period of total parenteral nutrition, the patient progressed well. Cardiovascular risk factors were addressed and outpatient follow up arranged.

Mesenteric ischaemia is a rare, but recognised, cause of terminal ileal ulceration and/or stricture and should be considered in the differential diagnosis of such cases.

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