Treatment Approach for Jejunitis with CT Findings of Edematous and Thickened Jejunum
The treatment approach depends critically on determining the underlying etiology of jejunitis, as management differs substantially between inflammatory bowel disease (Crohn's disease), eosinophilic jejunitis, infectious causes, and other inflammatory conditions—but initial management should include broad-spectrum IV antibiotics targeting gram-negative and anaerobic bacteria while pursuing definitive diagnosis through endoscopic evaluation with biopsy.
Initial Diagnostic Workup
The CT findings of edematous circumferential wall thickening at the jejunal-ileal junction require correlation with clinical presentation and further diagnostic evaluation 1:
Obtain detailed clinical history focusing on: duration of symptoms, presence of diarrhea (bloody vs non-bloody), weight loss, fever, prior GI symptoms, smoking history, food triggers, and family history of inflammatory bowel disease 2, 3.
Laboratory assessment should include: complete blood count with differential (looking for eosinophilia), inflammatory markers (CRP, ESR), celiac serologies (tissue transglutaminase IgA, total IgA), stool studies for infectious causes, and albumin level 2, 3.
Small bowel series or advanced enterography (CT enterography or MR enterography) is indicated to better characterize the extent of disease, assess for strictures, ulcerations, and complications 1. MR enterography is preferred in younger patients to minimize radiation exposure 1.
Differential Diagnosis Based on Imaging
The CT findings of jejunal wall thickening with edema have several important considerations 1:
Crohn's disease presents with asymmetric wall thickening, segmental hyperenhancement, mural edema on T2-weighted imaging, and may show ulcerations or restricted diffusion indicating severe inflammation 1.
Eosinophilic jejunitis can present with similar wall thickening and may be associated with eosinophilic ascites, often triggered by smoking or specific foods 3.
Jejunal diverticulitis presents as focal inflammatory mass involving proximal small bowel 4.
Ulcerative jejunitis/enteritis (complication of celiac disease) presents with ulcers that may extend beyond the duodenum, high risk of obstruction or bleeding 2.
Treatment Algorithm
If Crohn's Disease is Suspected or Confirmed:
Severity assessment guides therapy 1:
Mild inflammation (hyperenhancement, mild wall thickening without severe signs): Consider oral corticosteroids (prednisone 40-60 mg daily) or budesonide 9 mg daily, with transition to immunomodulators (azathioprine, 6-mercaptopurine) or biologics (anti-TNF agents) for maintenance 5.
Severe inflammation (marked wall thickening >7mm, ulcerations, high T2 intramural signal, restricted diffusion): Requires IV corticosteroids (methylprednisolone 40-60 mg daily or hydrocortisone 100 mg every 8 hours) with early consideration of biologic therapy 1, 5.
Complications (stricture, obstruction, abscess, fistula): Surgical consultation is mandatory 1. Percutaneous drainage for abscesses >4 cm combined with IV antibiotics (piperacillin-tazobactam) is first-line, reserving surgery for generalized peritonitis or hemodynamic instability 1, 6.
If Eosinophilic Jejunitis is Suspected:
Endoscopic evaluation with biopsy is essential to confirm eosinophilic infiltration 3, 7.
Initial therapy: Systemic corticosteroids (prednisone 40-60 mg daily or IV methylprednisolone if severe) with rapid clinical response expected 3, 7.
Maintenance therapy: Oral budesonide 9 mg daily for 3 months has been effective for obstructive eosinophilic jejunitis with minimal side effects 7. Addition of montelukast may provide benefit 3.
Identify and eliminate triggers: smoking cessation and dietary modification are critical for preventing recurrence 3.
If Infectious or Undifferentiated Jejunitis:
Empiric broad-spectrum IV antibiotics should be initiated immediately: piperacillin-tazobactam 3.375-4.5g every 6-8 hours or alternative regimens covering gram-negative and anaerobic organisms 1, 6.
Clinical monitoring for 48-72 hours to assess response 1, 4.
Surgical intervention is indicated if medical management fails, if perforation is suspected, or if obstruction develops 1, 4.
Endoscopic Evaluation Strategy
Double-balloon enteroscopy or device-assisted enteroscopy is the gold standard for direct visualization and biopsy of jejunal lesions 2, 3:
Allows assessment of mucosal inflammation, ulceration, and tissue sampling for histopathology 2, 3.
Histology should evaluate for: eosinophilic infiltration (>20 eosinophils per high-power field), villous atrophy (celiac disease), granulomas (Crohn's disease), and T-cell receptor clonal gene rearrangements (ulcerative enteritis/lymphoma risk) 2.
Critical Pitfalls and Red Flags
Do not delay endoscopic diagnosis when imaging shows jejunal inflammation, as treatment differs substantially between etiologies and empiric steroid therapy without tissue diagnosis can mask underlying malignancy 2.
Ulcerative enteritis in celiac disease carries 50% mortality and high risk of progression to enteropathy-associated T-cell lymphoma—corticosteroids are ineffective and aggressive therapy (cladribine, stem cell transplant) may be required 2.
Eosinophilic jejunitis can mimic acute abdomen with eosinophilic ascites—paracentesis showing eosinophilia can guide diagnosis when endoscopy is initially unrevealing 3.
Jejunal diverticulitis may require surgical resection if medical management with antibiotics fails 4.
Monitoring and Follow-up
Clinical response should be evident within 48-72 hours of appropriate therapy 1, 3, 7.
Repeat imaging (MR enterography preferred) at 8-12 weeks to assess mucosal healing in Crohn's disease or resolution in other inflammatory conditions 1.
Colonoscopy with ileoscopy should be performed in patients ≥40 years or with alarm features to exclude underlying neoplasm 8, 9.