Crohn's disease presenting as gastric outlet obstruction

Abstract

We present a unique presentation of Crohn's disease in a 25-year-old male with a 3-month history of progressive gastric outlet obstruction symptoms including reflux, vomiting, postprandial pain and weight loss, with no other symptoms. Multiple imaging investigations as well as gastroscopic biopsies revealed a non-specific prepyloric lesion, without evidence of malignancy. A distal gastrectomy was performed. Subsequent histological evaluation revealed gastroduodenal Crohn's disease. Follow-up revealed no evidence of disease elsewhere in the gastrointestinal system or systemically. While it is not uncommon for Crohn's disease to involve the stomach and duodenum, it is rare for gastroduodenal disease to be the initial presentation. Isolated gastroduodenal Crohn's disease typically presents with non-specific gastritis-like symptoms over a number of years. This patient had a unique course of Crohn's disease with rapid onset of symptoms, predominantly relating to gastric outlet obstruction and no prior or subsequent history of gastrointestinal symptoms.

Crohn’s disease of esophagus, stomach and duodenum

“…The presence of symptoms such as abdominal distension, postprandial vomiting, weight loss, and early satiety may indicate more severe disease, usually due to stenosis obstruction[ 53 ]. Gastroduodenal involvement usually manifests itself through insidious, gastritis-like symptoms, but there are reports of atypical conditions, with rapid progression to obstructive forms[ 52 , 54 ]. Less frequent presentations are upper gastrointestinal bleeding, delayed puberty, and chronic iron-deficiency anemia[ 49 , 55 ].…”

“…Isolated gastroduodenal CD represents a diagnostic challenge, since the histological analysis of biopsies may only demonstrate nonspecific inflammatory findings, and in some cases, only the study of the surgical specimens confirms the involvement of the UGT[ 54 ]. The series of cases reported by Nugent et al[ 25 ] did not demonstrate granulomas in biopsies taken by endoscopy.…”

Crohn’s disease presenting as gastric outlet obstruction: a therapeutic challenge?

“…In the previously reported cases, Scheck et al 6 opted for Billroth II distal gastrectomy with retrocolic gastrojejunostomy in their case. The gastrectomy specimen confirmed the diagnosis of gastric CD and the patient was subsequently initiated on azathioprine therapy.…”

“…Endoscopic findings in patients with gastric CD include nodularity (93%), aphthous ulcers (64%), thickened antral folds (64%), linear ulcerations (55%) and antral narrowing (43%) 6. The most widely used histological feature in the diagnosis is the presence of non-caseating granulomas 7–11.…”

Pyloric Stenosis: A Rare Manifestation of Crohn’s Disease

“… 1 The first documented case involving the stomach was published in 1949. 2 Crohn’s gastritis is commonly associated with Crohn’s duodenitis and is referred to as “gastroduodenal CD” and is reported in 0.5 −4.0% of cases of Crohn’s disease. 3 – 7 56% of patients with gastroduodenal CD had previous CD elsewhere in the gastrointestinal tract 5 and one third will develop distal disease later in life.…”