Intestinal ultrasound and its role in the acute setting: stenosing Crohn's disease and acute bowel obstruction due to foreign body ingestion (dental post and crown).

A 39-year-old woman with a history of Crohn's disease presents at the Emergency Room for a 2-hour long colicky abdominal pain with bloating, vomiting and no gas passing. She refers an accidental ingestion of a foreign body three weeks ago, a dental post and crown (she is currently using an invisible orthodontic technique). Her Crohn's disease affects the terminal ileum, and was diagnosed 8 years before, she has been suffering mild to no symptoms for the last years, but due to evidence of biochemical, endoscopic and ultrasonographic activity she is on Ustekinumab 90mg subcutaneously every 4 weeks, after Infliximab and Adalimumab loss of response. An abdominal x-ray reveals bowel dilation and hydro-aerial levels, as well as a radiopaque element in the pelvis consistent with the dental post and crown. CT-scan confirms the bowel obstruction, ileal stenosis is found. Intestinal ultrasound is performed at our centre finding a long ileal stenosis, 33 cm, thickened wall 5.6mm, destructuring of the layer pattern, hyperemia (modified Limberg score 3), ileoileal fistula with no collection associated, and a prestenotic dilation of 40 mm. The dental foreign body is found, non-impacted, in the prestenotic dilated loop. Even though an initial course of intraneous steroids is ordered, due to previous medical history of a persistent active Crohn's disease with loss of response to three advanced therapies, as well as the very low probability of progression of the foreign body along with the risk of permanent impaction or perforation, surgery is indicated. Ileocecal resection with extraction of the foreign body is performed uneventfully.