Gastroduodenal involvement as an unusual presentation of Crohn’s disease

Abstract

It is relatively uncommon for Crohn's disease to implicate the gastric and duodenal regions and occasionally it can cause pyloric stenosis, in which medical therapy may be ineffective and surgery might be required. We report two exceptional cases with prepyloric stenosis secondary to Crohn's disease, aiming to emphasize the clinical suspicion and to describe the diagnostic imaging procedure and surgical treatments. ResumenEs relativamente infrecuente que la enfermedad de Crohs afecte al estomago y duodeno y ocasionalmente puede producir estenosis pilórica, en estas situaciones el tratamiento médico suele ser ineficaz y se requiere tratamiento quirúrgico. Se exponen dos casos clínicos excepcionales de estenosis prepilórica asociada a la enfermedad de Crohn, dirigidos a enfatizar en la sospecha clínica y describir el diagnóstico y el tratamiento quirúrgico Enviado: 22-05-2016 Revisado: 22-07-2016 Aceptado: 01-08-2016 Carlos Actual. Med. 2016; 101: (798): 109-111 PATIENTS AND METHODS:Case Report 1: A 29-year-old woman, diagnosed with controlled ileocolonic Crohn's disease (CD) 7 years ago was admitted with abdominal pain accompanied by anorexia and weight loss (17Kg in a year).An upper endoscopy (UE) revealed a gastric retention and pyloric stenosis, with an inflammatory appearance. The endoscope could not pass through. A biopsy was taken. Negative H.pylori test.Because of the persistence of the symptoms, an endoscopic dilatation was performed up to 12mm due to pyloric stenosis. Furthermore, a MRI enterography was also realized. It revealed important signs of gastric distension and significant reduction of the pyloric region's lumen and first duodenal portion (Figure 1).Clinical deterioration progressed, leading to surgery. Findings showed gastric dilatation with hypertrophy of its wall, pre-pyloric stenosis and an apparently normal pylorus. A longitudinal incision was performed in the pylorus revealing a circumferential stenosis of the antrum 7-8 mm in diameter and a gastric wall hypertrophy with a characteristically "cobblestone" appearance. The mucosal defect was repaired and closed transversely using the Heineke-Mikulicz technique.Case Report 2: A 52-year-old-woman diagnosed with ileocolonic CD 8 years earlier, and with a surgical history of several procedures at the ileum site, was admitted with postprandial vomiting, accompanied by a very significant and painful abdominal distension with no further intestinal transit alterations.Transit studies with barium were conducted, showing an elongated shaped stomach. Moreover, slow emptying with important alterations in bowels' folds was assessed. The UE reported inflammatory stenosis in duodenum, unable to be traversed by the endoscope. Biopsies were taken, with results of intense nonspecific duodenitis. HP test (-). Adalimumab therapy was begun but within two months the patient started to show progressive clinical deterioration with postprandial vomiting and oral intolerance.Due to pyloric stenosis, MRI enterography was not indicated and alternative...