Campylobacter Enterocolitis: A Characteristic Shallow and Large Ulcer on the Ileocecal Valve

A 25-year-old man presented with acute onset of fever, abdominal pain, and hematochezia. He had had undercooked chicken five days before. On examination, the body temperature was 37.8℃ and there was tenderness on palpation at the right lower quadrant with increased bowel sounds. Laboratory examination showed white blood cells of 14,900/µL and elevated levels of C-reactive protein of 22.02 mg/dL (range, <0.14 mg/dL). A computed tomography (CT) scan showed marked thickening of the right colon (Fig. 1). Colonoscopy showed the marked inflammation of the ileocecal valve and the ascending colon (Fig. 2). A shallow and large ulcer on the ileocecal valve was noted (Fig. 3). As Campylobacter enterocolitis was suspected by the typical clinical course and imaging studies, clarithromycin was administrated. He improved in a few days and, later, standard stool culture showed negative but intraluminal fluid culture yielded Campylobacter jejuni.

FIG. 1. A computed tomography scan showed marked circumferential thickening and stratification of the right colon (arrowhead), pericolic fat stranding, and enlarged lymph nodes (arrow) adjacent to ileocecal vessels.

FIG. 2. Colonoscopy revealed an erythematous and edematous ileocecal valve with multiple aphthous ulcers and patchy erythema in the ascending colon.

FIG. 3. A shallow and large ulcer surrounding the stenotic lumen to the ileum (arrow) was observed on the ileocecal valve.

Campylobacter spices, such as C. jejuni, C. coli, and C. fetus, are the most common pathogens of bacterial enterocolitis. Regarding the portion of acute bacterial enterocolitis, Campylobacter, Salmonella, and Yersinia enterocolitis appear to be more prominent in the right colon, whereas the inflammation by Shigella occurs predominantly in the left colon by the imaging evaluation.1,2 Ileocecal area is affected by various diseases including infection, inflammatory bowel disease (Crohn's disease, ulcerative colitis), neoplasms, and diverticular disease, thus differential diagnosis can be difficult.3,4 A detailed study has disclosed clearly that large ulcers (≥10 mm) at the ileocecal valve are typical endoscopic feature for Campylobacter enterocolitis,3 as shown in this case. Sensitivity and specificity of the ileocecal valve ulcer are 100% and 73.7%, respectively, whereas those of the ulcer size (≥10 mm) are 100% and 33.1%, respectively.3 Although the reason for these features is unknown, these predictive values may aid the diagnosis of Campylobacter enterocolitis. In addition, intraluminal fluid culture via endoscopic aspiration can dramatically increase diagnostic yield over standard stool culture, especially for Campylobacter enterocolitis with the sensitivity of 90% (9/10) and 20% (2/10), respectively,3 as confirmed in this case.