An Unusual Case of Terminal Ileitis and Stricture that Mimicked Crohnʼs Disease

Purpose: Chronic inflammation in the terminal ileum (TI) suggests a cause for the patient's symptoms, especially when the clinical suspicion is Crohn's disease. Non-steroidal anti-inflammatory drugs, lymphoid hyperplasia, intestinal infections, lymphoma, infections and ulcerative colitis (UC) are some of the other causes of terminal ileitis. This is an unusual case of a 41-year-old multiparous female with past medical history of small bowel obstruction and colitis who presented with a 5-day history of crampy abdominal pain, nausea, vomiting, and diarrhea. On the CT scan of the abdomen she was found to have small bowel obstruction with segmental enteritis in close proximity to the terminal ileum. She was started on IV antibiotics and steroids, kept NPO and NG tube was placed to relieve the obstruction. Due to little improvement in the obstruction, she underwent exploratory laparotomy with resection of the narrowed small bowel segment with side to side anastomosis and appendectomy. Patient was started on temporary parenteral feeding, and continued on IV steroids for management of suspected inflammatory bowel disease. Strangely, the pathology results for the small bowel resection specimens showed presence of endometriosis in both the appendix and terminal small bowel segment without any evidence of inflammatory bowel disease. Her steroids were soon tapered off and with tolerance of oral feeds patient was discharged from the hospital with outpatient gynecology follow-up for management of endometriosis. Ileal endometriosis should be carefully considered in the differential diagnosis of Crohn's disease in menstruating females, especially the ones who are nulliparous and have dysmenorrhea, dyspareunia, dyschezia, menometrorrhagia, or other peri-menstrual symptoms. This case exemplifies the importance to not mistake endometriosis for Crohn's disease as they each have different therapeutic management.