Wednesday, 4 December 2013

Enteritis - Misdiagnosis and diagnosis

Acute Enteritis, in most cases is defined as a condition of inflammation of the small intestine as a result of eating and drinking contaminated water and foods infected by virus and bacteria. But according to the study by the University Hospital Aintree, chronic radiation enteritis is an increasing problem, as more patients receive radiotherapy as part of their cancer therapy and as the long-term survival of these patients improves(a). Other study indicated that acute radiation enteritis is almost inevitable in the curative treatment of malignant tumors of the abdomen and pelvic area. It is frequently a self-limiting disorder of intestinal function associated with reversible mucosal changes of the intestine(b). The prevalence of the disease although is decreasing, it still affects millions (approx 1 in 83 or 1.20% or 3.3 million people in USA ) of people in the U.S alone, according to the statistic. Chronic enteritis is a condition of inflammation caused by other health conditions, such as Crohn's or celiac disease.
Misdiagnosis and diagnosis
A. Misdiagnosis
1. Primary NK/T cell lymphoma
Primary natural killer (NK) cell like T cell lymphoma of the terminal ileum is extremely rare. It most frequently occurs in the nasal or paranasal areas and less frequently in the skin, the soft tissue, and the gastrointestinal tract. NK/T cell lymphoma involving gastrointestinal tract has characteristic endoscopic features of Inflammatory bowel disease. According to the study by the Hallym University College of Medicine, there is a case of primary NK/T cell lymphoma misdiagnosed as Behcet's enteritis of the terminal ileum colonoscopically and complicated by cecal bleeding and perforation(30).

2. Acute appendicitis
Acute appendicitis is the most common cause of urgent surgery in children. Bacterial enteritis limited to the ileocecal region appears to be responsible for an appreciable number of unnecessary appendectomies. On the other hand, diagnostic errors in appendicitis may delay early appendectomy and result in the formation of appendiceal mass(31).

3. Acute abdomen pain
Enteritis cystica profunda, an uncommon condition, is characterized by nonneoplastic cystic spaces within the wall of the small bowel. The third case of enteritis cystica profunda in children is presented with special emphasis on diagnosis and treatment. This rare entity may mimic acute abdomen and should be kept in mind in the differential diagnosis(32).

4. Others
Eosinophilic enteritis is a rare condition of unknown aetiology, although it is generally believed to be due to intestinal allergy. It may mimic peptic ulcer, subacute (or chronic) intestinal obstruction, gastroenteritis, irritable bowel syndrome, and inflammatory bowel disease. According to the study by, there is a case of Eosinophilic enteritis in a 27 year old woman the symptoms of which appeared within six weeks of childbirth. With repeated episodes of abdominal pain, vomiting, occasional loose stools with weight loss, she was investigated and treated for many weeks in three hospitals without success. All investigations were inconclusive. Finally laparotomy revealed inflamed segments of small bowel, a biopsy of which showed Eosinophilic enteritis. The patient was subsequently treated successfully with Prednisolone(33).

B. Diagnosis
Diagnosis is depending to the underlined causes of the diseases
1. Stool culture
The aim of the test is to identify the bacteria and virus which cause the diseases. According to the study of "New methods for detection of campylobacters in stool samples in comparison to culture" by the University Hospital, Frankfurt/Main, current detection in stools is done essentially by culture on selective and nonselective media with filtration. These methods were compared to 2 molecular biology methods, an in-house real-time PCR and a multiplex PCR named Seeplex Diarrhea ACE Detection, and 3 immunoenzymatic methods, Premier Campy, RidaScreen Campylobacter, and ImmunoCard Stat!Campy. Out of 242 stool specimens tested, 23 (9.5%) fulfilled the positivity criteria, i.e., they were positive by one or both culture methods or, in case of a negative culture, by a positive molecular method and a positive immunoenzymatic method. The striking feature of this study is the low sensitivity of culture, in the range of 60%, in contrast to immunoenzymatic and molecular tests(34).

2.  [13]C-acetate breath test
[13C]acetate breath test is the measure of gastric emptying of the liquid phase both in liquid and semisolid test meals by simultaneous radioscintigraphy.There is a report of eosinophilic enteritis in which the (13)C-acetate breath test was effective(35).
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