Introduction:
Cecal ulcers refer to mucosal breaks over the cecum or ileocecal valve. Cecal ulcerations can be single or multiple. They can be encountered in several diseases including infectious colitis, inflammatory bowel disease, and malignancy. Even after a biopsy, the diagnosis may be inconclusive. In cases such as patients with profound bleeding, for definite treatment and diagnosis, surgical intervention is necessary. Sometimes when the preoperative diagnosis is difficult, close follow-up is suggested in cases that are managed conservatively.
Cecal ulcers are at times encountered in asymptomatic patients. It has not been evaluated whether these patients represent the earliest course of clinically significant disease. The endoscopic and clinical characteristics that may predict the development of diseases such as inflammatory bowel disease are unknown.
How to Diagnose Cecal Ulcers?
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Cecal ulcers are diagnosed based on the evaluation of symptoms or the findings of the colonoscopy. In the case of asymptomatic patients who take NSAIDs (nonsteroidal anti-inflammatory drugs), occult blood loss or blood loss anemia may be seen. About 3 % of people who take NSAIDs regularly have colonic ulcers.
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Colonoscopy findings show ulcers on the anterior wall of the cecum or on the antimesenteric border within two centimeters of the ileocecal valve. These ulcers are surrounded by significant edema.
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The results of the biopsy are nonspecific, though thickening of the muscularis mucosae, fibrinous granulation tissue, and lymphocyte and fibroblast infiltration with disruptions have been described.
What Are the Endoscopic Features of Asymptomatic Cecal Ulcers?
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The number of ulcers ranges from one to ten.
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The size of ulcers ranges from less than 1.5 cm to 2 cm.
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Ulcers are found with irregular folds.
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Terminal ileum involvement can also be seen.
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The time to spontaneous endoscopic remission was 24 months.
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The longest endoscopic follow-up period was 47.5 months.
What Is the Clinical Course for Patients With Asymptomatic Cecal Ulcers?
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Based on the findings of granulomatous inflammation and positive acid-fast stain bacilli in the histological study, intestinal tuberculosis was diagnosed.
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In another case where the patient was diagnosed with intestinal tuberculosis, the histologic results were basal lymphoplasmacytosis or glandular distortion and active follicular colitis without granuloma.
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In both the above cases, the lesions resolved after treatment with antituberculosis medications.
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In a case where the patient suffered from weight loss and pain in the right lower abdomen three years after the first diagnosis of cecal and terminal ileum ulcers, it was seen through repeated colonoscopy that ulcerations were confined over the terminal ileum and cecum, without much progression. After endoscopy, Crohn's disease was diagnosed on the basis of findings such as the presence of cryptitis and crypt distortion, and crypt abscess. The diagnosis was made after a complete survey including abdominal computed tomography and lab tests that excluded other possibilities.
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A patient was well for 3 years when bloody stool occurred and peri-appendiceal shallow ulcers and ulcers in the terminal ileum were noticed. In this case, ulcerative colitis was diagnosed. The diagnosis was based on proctitis with typical shallow ulcers and persistent peri-appendiceal and terminal ileum involvement.
Conclusions:
The endoscopic features in patients with asymptomatic cecal ulcers include terminal ileum involvement, larger size ulcers, and ulcers with an irregular fold. These features may predict the development of clinically significant diseases. If these features are present in asymptomatic patients then they should be closely monitored. Cecal ulcers clinical outcomes and management recommendations remain uncertain.
