PICTURES IN DIGESTIVE PATHOLOGY

 

Crohn's disease presenting as pyloric stenosis

Estenosis pilórica, debut de enfermedad de Crohn

 

 

M.^a Lourdes Ruiz-Rebollo¹, M.^a Lourdes del-Olmo Martínez¹, Ana Macho-Conesa¹, Juan Ramón Gómez-López², María Álvarez-Quiñones³ and José Manuel González¹

Departments of ¹Digestive Diseases, ²General Surgery, and ³Pathology. Hospital Clínico Universitario. Valladolid, Spain

 

 

Case report

An upper gastrointestinal endoscopy was performed on a 78 year-old woman affected of bloating and mild anemia. Her medical history included high blood pressure, diabetes mellitus and hypercholesterolemia. She had been performed a cholecystectomy and hysterectomy several years before. Apart from a mild hypochromic anemia she was on a good health, her physical exploration didn't revealed any pathological signs and the rest of the blood analysis only disclosed low iron levels.

Gastroscopy showed a normal stomach with no food residue in it. The antrum was retracted and an ulcerated and stenotic pylorus was seen (Figs. 1 and 2) which could be passed through, showing a normal duodenum. On taking biopsies it was hard on touch and moved as a whole but the histological study only disclosed scar tissue without malignancy. The patient was put on high dose of proton pump inhibitors and scheduled for a new endoscopy in 4 weeks.

The second endoscopy revealed the same picture but this time it was impossible to get through the pylorus and reach the duodenum; biopsies again did not help us. A CT scan showed gastric food retention and thickening of antrum and pylorus without pathological lymph nodes. Due to the lack of improvement she was sent to surgery. On the operation an inflammatory pyloric mass was detected with several lymph nodes surrounding. A partial distal gastrectomy with jejunal anastomosis was performed. The histology study showed an acute and chronic inflammatory of the pylorus with small aphtoid ulcers and non-caseating granulomas (Fig. 3). The patient did well after surgery and was discharged and controlled as an outpatient.

 

Discussion

Crohn's disease can affect the entire gastrointestinal tract. Colon and distal ileum are the most frequent areas affected. However, with the widespread use of upper endoscopy nowadays, gastroduodenal involvement is more frequently seen (1). Pyloric stenosis alone is not so common and there are only a few cases published (2,3). When we first attended this patient, several other etiologies came to our mind such as peptic ulcer disease or an ulcerative stricture due to anti-inflammatories so she was put on proton pump inhibitors.

As her symptoms did not improved in a month and the stenosis went even worse, a neoformative process was the concern. Biopsies performed were not conclusive, so surgical treatment was indicated. The histological study of the resected antrum revealed us the correct diagnosis.

Intestinal strictures in Crohn's disease are often seen (4) and there are several options for treatment. Fibrosis is common so medical treatment is hardly effective. Endoscopic dilatation (5) has proved to be a save procedure with long term efficacy even with active disease. Surgery would be the last option.

So, clinicians must be aware of the possibility of dealing with patients affected with isolated strictures as the only symptom of Crohn's disease and offer them a conservative treatment.

 

References

1. Reynolds HL, Stellato TA. Crohn's disease of the foregut. Surg Clin North Am 2001;81(1):117-35.         [ Links ]

2. Nakamura H, Yanai H, Miura O, Minamisono Y, Mitani N, Higaki S, Tada M, et al. Pyloric stenosis due to Crohn's disease. J Gastroenterol 1998;33:739-42.         [ Links ]

3. Awad J, Farah R, Reshef R, Cohen H, Horn I. Pyloric stenosis as a presenting symptom of Crohn's disease. J Gastrointestin Liver Dis 2006;15(2):175-7.         [ Links ]

4. Vanrell Garau M, Ginard Vicens D, Llompart Rigo A, Mariño Méndez Z, Bosque López MJ, Ortega Moya P, et al. Impactación de un cuerpo extraño en un paciente con enfermedad de Crohn. Gastroenterol Hepatol 2009;32(5):339-42.         [ Links ]