a 65-year - old man with intermittent , colicky periumbilical pain which first occurred two months earlier was admitted to hospital .
he had an eight - year history of congestive heart failure caused by mitral valvular regurgitation and atrial fibrillation .
he was nonalcoholic , and there was no history of diarrhea , hematochezia , or melena .
vital signs at admission were stable , and laboratory findings including white blood cell count , a liver function test and electrolytic balance were within the normal ranges .
electrocardiography revealed atrial fibrillation , and chest radiography demonstrated cardiomegaly ( not shown ) . to exclude acute appendicitis , initial ultrasonography ( us )
was performed , and this demonstrated diffuse , segmental , concentric wall thickening of the terminal ileum just proximal to the ileocecal valve .
nonspecific ileitis , crohn 's disease , intestinal tuberculosis or ischemic enteritis were suggested as possible causes of the bowel wall thickening , and in order to evaluate the terminal ileum , colonoscopic examination was performed .
the ascending colon was found to be completely obstructed by a circumferential mass lesion , and the colonoscopic fiber could not be advanced further .
subsequent ct scanning showed a markedly dilated small bowel and ascending colon , with concentric , hyperattenuating , focal wall thickening in the hepatic flexure of the ascending colon ( fig .
in addition , the terminal ileum was dilated and showed diffuse , concentric wall thickening of its long segments with heterogeneous contrast enhancement . in the thickened wall ,
there appeared to be several possible diagnoses , including ischemic enterocolitis caused by thromboembolism of mesenteric vessels arising from atrial fibrillation , inflammatory bowel disease involving the ascending colon and terminal ileum , and ischemic or infectious enteritis associated with colon cancer .
stool culture yielded lactose - fermenting gram - negative bacillus , urine culture yielded citrobacter freundii , and gram staining of urine revealed the presence of gram - negative rods ; no organisms were isolated from blood cultures .
in addition to conservative management of congestive heart failure , the patient underwent antibiotic therapy with amoxacillin , tobramycin or aztreonam for two weeks and ciprofloxacin for several days .
symptoms such as abdominal pain ameliorated , the level of bowel sound decreased , and laboratory findings continued to be within normal ranges .
vital signs were stable , except for intermittent fever of up to 38.2 until 30 days after admission . at this time ,
, the hepatic flexure of the ascending colon was found to be completely obstructed by a hard concentric mass , and about 15 cm of the terminal ileum , just proximal to the ileocecal valve , was markedly dilated and diffusely thickened .
a cut section of the thickened terminal ileum revealed marked submucosal edema to a depth of approximately 10 mm , though there was no evidence of mucosal lesion .
microscopic examination also showed that the mucosal folds of thickened ileal loop were blunted by submucosal edema and there was extensive inflammatory reaction , with infiltrations of neutrophils . in some areas of the thickened bowel wall
neutrophil infiltration extended into the subjacent muscular layer and even to the serosa ( fig .
1d ) . the inflammatory reactions provided no evidence of granuloma formation , and the histologic findings were consistent with phlegmonous enteritis
phlegmonous enterocolitis is a rare inflammatory bowel disease with a high mortality rate of at least 60% .
the association between this disease entity and a variety of liver diseases has been well documented ( 1 - 3 ) , though cases associated with lobar pneumonia , pharyngitis , infected peritoneojugular venous shunt and septicemia have been reported , and it has also occurred in healthy individuals ( 1 , 4 - 6 ) .
several kinds of pathognomic bacteria have been demonstrated in culture or histologically ( 1 - 6 ) : gram staining of intestinal lesions has revealed a variety of entities such as streptococci , gram - positive cocci , and gram - negative or -positive rods .
the mortality rate associated with this disease continues to be high due to delayed diagnosis ( 1 - 5 ) .
thus , most cases reported in the literature were discovered at autopsy or after the examination of surgical specimens following surgery ( 1 - 6 ) .
some reports have suggested that earlier diagnosis and surgical resection of diseased bowel , together with the use of broad- spectrum antibiotics , has led to a good outcome ( 1 , 6 ) . the pathogenesis of this disease entity is not clear : ito et al .
first , the direct toxic effect of alcohol may affect the gastrointestinal tract , and prolonged alcohol ingestion leading to changes in the intestinal mucosa , with increased intestinal permeability ; subsequent penetration of the lamina propria by antigens ( organisms ) from the intestinal lumen results in a local antibody response .
second , in chronic alcoholism , the systemic and mucosal immune mechanisms are impaired , and this may exacerbate bacterial infection . it is not known why the organisms involved in phlegmonous enteritis are confined to the submucosa .
bowel wall edema associated with portal hypertension has been described in liver cirrhosis , and the loose connective tissue in the submucosa can be excellent soil for the rapid and diffuse spread of the organisms involved in an episode of bacteremia ( 5 ) .
first , the patient was not alcoholic and had no evidence of liver disease or septicemia .
second , his clinical course was silent for a long period , being discovered only at surgery ; previously reported cases , on the other hand , manifested an acute and serious clinical course , one which led even to sudden death . in our case ,
the early use of broad - spectrum antibiotics might have helped his condition to persist .
the literature in english includes only one case report dealing with the radiologic findings pertaining to this disease .
mooney et al . ( 6 ) reported the ct findings in one case , in which only nonspecific small bowel wall thickening with a small amount of ascites was noted . in our case ,
the terminal ileum showed marked wall thickening , and thumbprinting and blunted mucosal folds were revealed by ultrasonography .
the hypoattenuating focal areas in this thickened wall , shown at microscopic examination to be submucosal abscesses , are , in our case , thought to provide a clue to the diagnosis of phelgmonous enteritis .
 phlegmonous enteritis is a rare infective inflammatory disease of the intestine , predominantly involving the submucosal layer . 
 it is difficult to diagnose and often fatal . 
 its association with alcoholism and various liver diseases , although rarely reported , is well documented . 
 we report a case of phlegmonous enteritis in a male patient with congestive heart failure and colon cancer , and describe the ultrasonographic and ct findings . 
CASE REPORT
DISCUSSION