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Gastric Crohn’s Disease: A Rare Cause of Intermittent Abdominal Pain and Vomiting

Upper gastrointestinal study with Gastrografin (Bracco Diagnostic Inc, Monroe Township, NJ) revealed irregularity of the distal antrum in the prepyloric region and marked narrowing of the pylorus, duodenal bulb, and postbulbar duodenum (arrow).

Upper gastrointestinal study with Gastrografin (Bracco Diagnostic Inc, Monroe Township, NJ) revealed irregularity of the distal antrum in the prepyloric region and marked narrowing of the pylorus, duodenal bulb, and postbulbar duodenum (arrow).

Crohn’s disease is a chronic idiopathic inflammatory disease that may involve any part of the gastrointestinal tract from the mouth to the anus. It most commonly affects the terminal ileum and cecum, and less commonly is isolated to the colon. Crohn’s disease involving the stomach or duodenum is uncommon and described in only 0.5% to 4% of patients.1 A 17-year-old girl was referred to our hospital with a 6-year history of intermittent abdominal pain and vomiting, which worsened during the recent 2 months with a 3-kg weight loss. She had no history of abdominal surgery or trauma, and denied chronic hepatitis virus infection or any use of nonsteroidal anti-inflammatory drugs. She had undergone gastroscopy examination at the local hospital and was diagnosed with nonatrophic gastritis with gastric outlet obstruction. She was treated with antibiotics and antacids, but without significant relief. On admission, the patient was unable to tolerate oral intake other than minimal amounts of water, and physical examination revealed mild tenderness of the upper abdominal quadrant. Laboratory blood analyses including serum tumor markers, adenosine deaminase activity, and anti-tuberculosis antibody were all within normal limits, whereas erythrocyte sedimentation rate (22 mm/h, normal range, 0-15 mm/h), lymphocyte ratio (59.5%, normal range, 20%-50%), and free fatty acids (107.0 μmol/d, normal range, 10.0-85.0 μmol/d) were elevated. Her stool microscopy was positive for occult blood but negative for ova, cysts, or parasites. Upper gastrointestinal study with Gastrografin (Bracco Diagnostic Inc, Monroe Township, NJ) revealed irregularity of the distal antrum in the prepyloric region and marked narrowing of the pylorus, duodenal bulb, and postbulbar duodenum (Figure 1). In addition, diffuse cobblestone mucosal changes were present throughout the body of the stomach, and a bamboo joint-like appearance of the gastric body (Figure 2) was detected. The contrast-enhanced computed tomography (CT) scan showed multiple projections with slight enhancement along the gastric walls (Figure 3A-C), as well as slight enhancement and thickening of the pylorus (Figure 3D-F). Endoscopic ultrasound showed focal thickening of the gastric mucosal and submucosal layers with hypoechoic layer (Figure 4A). In addition, endoscopic ultrasound demonstrated significant circumferential thickening of the pylorus without normal stratification of the walls (Figure 4B).

Assessment

The patient underwent esophagogastroduodenoscopy examination, which revealed erythema (Figure 5A), longitudinal ulcers (Figure 5A), and cobblestone-like lesions in the gastric body. In addition, esophagogastroduodenoscopy also showed mucosal edema, erosion, and narrowing of the pyloric antrum (Figure 5B). Histopathologic examination of biopsies from involved areas in the stomach demonstrated nonspecific acute and chronic inflammation with massive neutrophil and lymphocyte infiltration (Figure 5C), and acid-fast staining did not reveal any acid-fast bacilli. These results were compatible with the previous biopsy samples of the stomach, which did not detect granulomas, malignancy, caseation, or tubercle bacilli. To evaluate the extent of the disease and provide important diagnostic clues, ileocolonoscopy was performed, which demonstrated areas of polypoid hyperplasia in the terminal ileum (Figure 5D), whereas the colon and rectum were normal (Figure 5E). Histopathologic examination of biopsies from terminal ileum showed granuloma, superficial small ulcers, and chronic inflammatory cell infiltration (Figure 5F).

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-Xu-Ting Zhi, MD, Jian-Guo Hong, MD, Tao Li, MS, Dong Sun, MS, De-Xin Yu, MD, Zhi-Qiang Chen, MD, Tao Li, MD

This article originally appeared in the May 2017 issue of The American Journal of Medicine.

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