35 years old male with diarrhea and weight loss

History
35 years old male with recurrent episodes of diarrhea for 1 year. Presentation with Quick value <10%, iron deficiency anemia, and vitamine B12 deficiency.

Imaging findings
At MRI enterography there is segmental ileal wall thickening with evidence of fat tissue within the thickened bowel loop (A, T2-weighting). The contrast-enhanced scan in coronal orientation shows mesenteric vessels reach into center of this finding (B). The T2-weighted coronal image shows an increase of the number of ileal folds (C, left), and a reduction of jejunal folds (C, right). There is mesenteric adenopathy (D, contrast-enhanced T1-weighting with fat saturation). At repeat imaging 4 weeks later the thickened ileal bowel loop was not present any more (not shown).

Diagnosis
Malabsorption syndrome due to celiac disease with transient ileal intussusception.

Discussion
Celiac disease is a gluten-sensitive enteropathy of the gastrointestinal tract that affects the small intestine in genetically susceptible individuals. It was previously thought to be a disease of childhood, but now adult presentation is increasingly common, and the disease can occur at any age.

MRI findings of celiac disease can be divided into intraluminal and extraluminal findings, but are not necessarily specific for celiac disease. 5% of patients with celiac disease do not have any macroscopic abnormalities of the small bowel.

The most specific observations in celiac disease are fold pattern abnormalities. In the normal small bowel there is a greater number of folds in the jejunum than in the ileum. Abnormalities of the intestinal fold pattern in celiac disease are defined qualitatively as a decreased number of jejunal folds (<3 folds per inch) and/or an increased number of ileal folds (>5 folds per inch, „ileal jejunization“). The presence of both phenomena is termed as jejunoileal fold pattern reversal and is highly suggestive for celiac disease. Bowel dilatation and bowel wall thickening may also occur.

A common finding in patients with celiac disease is ileal intussusception, which is most often asymptomatic and transient. Transient intussusception is presumably related to uncoordinated peristalsis in dilated loops of small bowel and is more frequently found in patients with severe celiac disease. When the intussusception is less than 3 cm long, occurs in the absence of a lead-point tumor, and is not responsible for small bowel obstruction, the findings are consistent with transient and self-limiting small bowel intussusception. However, because gastrointestinal malignant tumors can cause intussusception in adult patients with celiac disease and because in celiac disease there is a higher frequency of intestinal lymphoma and adenocarcinoma, imaging has to be carefully analyzed for confident exclusion of malignancy. Mesenteric adenopathy and mesenteric vascular engorgement are unspecific observations in patients with celiac disease.

Although small-intestine biopsy is mandatory to confirm the diagnosis, imaging may be useful in suggesting celiac disease in adult patients with intestinal disorders and low clinical index of suspicion for celiac disease. Moreover, imaging is especially useful in patients with known celiac disease and abdominal pain to exclude complications, such as intestinal intussusception, lymphoma, or adenocarcinoma.

Teaching points

  • Celiac disease is a rare radiological diagnosis with subtle imaging findings.
  • Imaging may provide crucial hints pointing at celiac disease in patients with chronic abdominal complaints.

Recommended reading
Masselli et al.
Celiac Disease: Mr Enterography and Contrast Enhanced Mri
Abdom Imaging (2010) 35:399,

Paolantonio et al.
Adult Celiac Disease: Mri Findings
Abdom Imaging (2007) 32:433

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