What are the causes and treatment options for terminal ileitis with small bowel obstruction, multiple hemorrhagic ovarian cysts, and inflammation causing moderate right hydronephrosis (Impaired renal function)?

From the Guidelines

Terminal ileitis with small bowel obstruction, hemorrhagic ovarian cysts, and right hydronephrosis requires prompt medical and possibly surgical intervention, with the most recent evidence from 2020 suggesting that radiologic imaging plays a key role in diagnosis and management 1. The most common cause is likely Crohn's disease, which can inflame the terminal ileum leading to strictures and obstruction. Other potential causes include infections (tuberculosis, Yersinia), NSAID-induced enteropathy, or malignancy. The ovarian cysts and hydronephrosis are likely secondary complications from inflammation spreading to adjacent structures. Treatment begins with:

• Bowel rest
• IV fluids
• Nasogastric tube decompression for the obstruction, as recommended by a 2019 study 2 Broad-spectrum antibiotics (such as piperacillin-tazobactam 4.5g IV every 8 hours or ceftriaxone 2g daily plus metronidazole 500mg IV every 8 hours) should be started. If Crohn's disease is confirmed, corticosteroids (prednisone 40-60mg daily) and later immunomodulators (azathioprine 2-3mg/kg/day) or biologics (infliximab 5mg/kg at weeks 0, 2, 6, then every 8 weeks) are indicated. Surgical intervention may be necessary for persistent obstruction, including resection of the affected bowel segment. The ovarian cysts may require gynecological evaluation and possible laparoscopic drainage if symptomatic. The hydronephrosis should resolve with treatment of the underlying inflammation, but urology consultation is warranted to monitor kidney function and consider temporary ureteral stenting if severe, as suggested by studies from 2016 3, 4 and 2008 5. The primary goal of treatment should be to improve quality of life, reduce morbidity, and prevent mortality, with a focus on individualized care based on the patient's specific condition and needs 1. Some key considerations in management include:
• The use of pharmacologic measures, such as opioids, antiemetics, and corticosteroids, to manage symptoms and prevent complications
• The potential benefits and risks of surgical intervention, including the risk of bowel ischemia and the need for careful patient selection
• The importance of multidisciplinary care, including involvement of gastroenterology, surgery, and urology specialists, to ensure comprehensive management of the patient's condition.

From the Research

Causes of Terminal Ileitis

• Terminal ileitis can be caused by a variety of diseases, including Crohn's disease, infectious diseases, spondyloarthropathies, vasculitides, ischemia, neoplasms, medication-induced, eosinophilic enteritis, and others 6
• The clinical presentation of terminal ileitis may vary from an acute and self-limited form to a chronic and debilitating course complicated by obstructive symptoms, hemorrhage, and/or extraintestinal manifestations 6
• Terminal ileitis may also be associated with small bowel obstruction, which can be caused by adhesions, hernias, neoplasms, Crohn's disease, and other conditions 7

Treatment of Terminal Ileitis

• The treatment of terminal ileitis depends on the underlying cause and may involve medical therapy, such as antibiotics, anti-inflammatory medications, and immunomodulators, or surgical intervention, such as laparoscopic ileocaecal resection 8, 9
• Laparoscopic ileocaecal resection has been shown to be a cost-effective treatment option for patients with Crohn's disease and terminal ileitis, with similar quality-of-life outcomes to treatment with infliximab, an anti-tumour necrosis factor (TNF) drug 9
• Medical resuscitation, including intravenous hydration, correcting electrolyte abnormalities, and nasoenteral suction, may also be necessary to manage small bowel obstruction and prevent complications such as bowel perforation and necrosis 7

Treatment of Small Bowel Obstruction

• The treatment of small bowel obstruction typically involves medical therapy, such as intravenous hydration and nasoenteral suction, and may require surgical intervention if the obstruction is complete or if there are signs of bowel ischemia or perforation 7
• Abdominal CT with oral and intravenous contrast is highly sensitive and specific in detecting and characterizing small bowel obstruction, and can help guide treatment decisions 7

Treatment of Hemorrhagic Ovarian Cysts and Inflammation

• The treatment of hemorrhagic ovarian cysts and inflammation typically involves surgical intervention, such as laparoscopic ovarian cystectomy, and may also involve medical therapy, such as pain management and hormonal therapy 8
• The treatment of moderate right hydronephrosis typically involves addressing the underlying cause, such as relieving the obstruction or treating the infection, and may require surgical intervention, such as ureteral stenting or nephrostomy tube placement 7