Diffuse enteric ischemia due to Wegener’s granulomatosis revealed by capsule endoscopy (with video)

A 26-year-old man with an unremarkable medical history presented with arthralgia and abdominal pain. Two days after admission, while under investigation for multiple arthritis, he suffered hematochezia, weakness, and low blood pressure. Esophagogastroduodenoscopy showed no abnormalities, but colonoscopy and retrograde ileoscopy revealed clots of blood through the whole enteric lumen. No sign of active bleeding was found. Mesenteric angiography was normal. Capsule endoscopy was performed 2 days later and revealed findings compatible with enteric ischemia (necrotic areas of mucosa, diffuse ulceration and blood in the lumen), mainly in the ileum ([Figs. 1], [2]; [Video 1]). A few days later, due to severe deterioration of his condition (acute abdomen), the patient underwent surgery. Surgical exploration revealed intraluminal inflammation, ulcerations, and necrotic areas in several sites in the ileum, in agreement with the findings of capsule endoscopy. A partial enterectomy with ileostomy was performed. Histological examination of the resected ileum showed injuries to the enteric wall and the mesentery of the terminal ileum compatible with necrotic–granulomatous vasculitis of small and intermediate-sized vessels (Wegener’s granulomatosis) ([Figs. 3], [4]).

Fig. 1 Necrotic area of mucosa.

Fig. 2 Diffuse ulceration and blood in the lumen.

Fig. 3 A medium-sized artery in the mesentery with necrotizing vasculitis (H&E, orig. mag. × 25).

Fig. 4 At higher magnification, a Langerhans-type giant cell can be seen (H&E, orig. mag. × 100).

Video 1 Capsule endoscopy shows findings compatible with enteric ischemia: necrotic areas of the mucosa, ulcerations, erythema, edema, and blood in the lumen of the ileum.

During the postoperative follow-up, the patient is doing well. We emphasize the role of capsule endoscopy: (i) in finding the cause of the gastrointestinal bleeding, (ii) in guiding the surgeon to surgical intervention when a serious clinical entity appeared, and (iii) in the early diagnosis of ischemic–necrotic enterocolitis even in this rare case of intestinal involvement in Wegener’s granulomatosis.

Endoscopy_UCTN_Code_CCL_1AC_2AD