Crohn Disease of the Duodenum, Stomach, and Esophagus

Introduction

Crohn disease (CD) has a propensity for involvement of the terminal ileum and colon but also can occur throughout the gastrointestinal tract. When it occurs in the esophagus, stomach, and duodenum, it presents challenges in diagnosis and management. The type of detailed assessment of the upper gastrointestinal (UGI) tract by endoscopy and histology that is now widely available suggests that asymptomatic synchronous UGI involvement occurs in 30% to 50% of patients with ileocolonic disease. UGI CD is most commonly found in the gastric antrum, duodenal bulb, and duodenal loop. Isolated, clinically significant esophageal CD is unusual and is the source of less than 2% of complaints in patients with CD. Symptomatic gastroduodenal strictures are also rare and are found in fewer than 4% of patients with CD. In patients with concomitant ileocolonic disease, treatment of UGI inflammation is often dictated by medical treatment for the primary site. In the presence of obstructive symptoms, endoscopic therapy or surgery is indicated.

Clinical Presentation

Symptoms of upper GI CD depend on both the clinical nature and distribution of disease. The CD is most often stricturing, with penetrating disease uncommon. Dysphagia, odynophagia, and pyrosis suggest esophageal involvement. Weight loss may occur as a result of these symptoms or as a systemic manifestation of CD. Anorexia, epigastric pain, nausea, and dyspepsia raise the possibility of gastroduodenal involvement, whereas vomiting with weight loss or anemia suggests progression.

The most common symptom is the rapid development of painful dysphagia that leads to substantial weight loss resulting from restriction of oral intake. The absence of heartburn and regurgitation is an important point that weighs against the more common reflux esophagitis. Approximately half of the patients affected by Crohn-related esophagitis will have a history of involvement of other portions of the gastrointestinal tract. In advanced disease, symptoms of obstruction may be present as a result of fixed stenotic segments. Postprandial vomiting, abdominal distension, epigastric pain, and rapid weight loss are indicative of gastric outlet obstruction, and when diarrhea, abdominal pain, weight loss, and an abdominal mass occur, the diagnosis of internal fistulae should be considered. Fever, tenderness, and an underlying mass, sometimes with associated cutaneous sinus, suggest incipient fistulization.

The most well-known criteria for the diagnosis of gastroduodenal CD are those of Nugent and Roy, which are the presence of either:

• 1.

  A histologic finding of noncaseating granulomatous inflammation of the stomach or duodenum, with or without concomitant CD in the remaining gastrointestinal tract, and the absence of other systemic granulomatous disorders

• 2.

  Confirmed CD of the gastrointestinal tract and radiographic or endoscopic findings of diffuse inflammation of the stomach or duodenum consistent with CD

Most patients with gastroduodenal CD are asymptomatic. The most common symptom is epigastric abdominal pain, which is often postprandial, nonradiating, and usually relieved by the ingestion of food and antacids. Pronounced, continuous abdominal pain associated with nausea and vomiting suggests gastric outlet obstruction as a result of stricture. Other common symptoms include profound weight loss, nausea with or without vomiting, and anorexia. Gastrointestinal blood loss may be indirectly noted in patients with gastroduodenal CD, usually in the form of chronic anemia. Melena and hematemesis suggest more significant bleeding, but this finding is rare.