Three cases of apparent primary villous atrophy of the terminal ileum in women with chronic diarrhoea are reported. Eight cases have previously been reported in the literature. Clinical characteristics are the presence of severe chronic secretory diarrhoea with episodes of hypokalaemia combined with signs of ileal malabsorption and/or eYcacy of cholestyramine. Diagnosis is based on ileoscopy and histology. An association with microscopic colitis was present in the three patients and in four cases in the literature. The pathogenesis of primary ileal villous atrophy remains unknown and may involve dysimmunity. Its association with microscopic colitis may indicate a common pathogenesis or support the hypothesis that the faecal stream or bile salts play a role in the pathogenesis of microscopic colitis. (Gut 1997; 41: 561-564) Keywords: intestinal villous atrophy; ileum; secretory diarrhoea; bile acid malabsorption; microscopic colitis Villous atrophy of the terminal ileum is usually seen in patients with villous atrophy involving the whole length of the small bowel. The main aetiologies are coeliac disease and immunodeficiency syndromes, including HIV related immunodeficiency, common variable hypogammaglobulinaemia, and IgA deficiency. Ileal villous atrophy is seldom seen in the absence of duodenojejunal atrophy; its aetiologies are listed in
Case reportsThe three patients (RM, DO, and ML) were women with severe chronic diarrhoea. Table 2 shows their main clinical characteristics. They were not taking any medication. The history of RM included the alternation of diarrhoea and constipation for 50 years, ovariectomy for benign ovarian neoplasm in 1938, tuberculous pleuritis in 1939, three episodes of intestinal obstruction due to adhesions, and hysterectomy in 1980 to treat an epidermoid carcinoma of the uterine cervix. The other two patients had no relevant history except for appendectomy.
BIOLOGICAL AND MORPHOLOGICAL
EXPLORATIONSCommon features of the three patients were the presence of high erythrocyte sedimentation rate of 35, 30, and 5-42 mm/h for RM, DO, and ML respectively, and a history of transient hypokalaemia (2-3.5 mEq/l). Table 2 presents results of ileal function tests. The results of the following laboratory investigations were in the normal range: haemoglobin; blood urea, glucose, uric acid, calcium, magnesium, iron, folates, and vitamin B 12 ; albumin, globulin fractions, plasma immunoglobulins, cholesterol, prothrombin time, D-xylose test; and stool analysis for pathogenic bacteria and parasites. Repeated searches for laxatives in the stools (phenolphthalein) and urine (anthraquinones) were negative. Faecal osmolarity was normal (280-320 mmol/l), and faecal electrolytes displayed an osmotic gap below 50 mmol/l. Levels of thyroid stimulating hormone (TSH), triiodothyronine, and thyroxine were in the normal range for RM and ML. DO had high TSH values (15.9 µg/ml (normal <4.5) and low triiodothyronine and thyroxine concentrations. Concentrations of serum vasoactive peptide, serotonin, and c...
