Proximal Crohn's Disease: Review of the Clinicopathologic Features and Therapy

Abstract

Crohn's disease in the proximal region of the digestive tract is uncommon. Better diagnostically procedures and more careful histologic examination has led to a higher detection of proximal Crohn's disease. The diagnosis is based on symptoms, endoscopy with serial sections, or double contrast radiography. The most common histologic finding for this diagnosis are granulomas in the mucosa in Helicobacter pylori-negative patients, but the granulomas are not always frequently detected. Endoscopic lesions in the proximal regions look like the lesions that could be found in the distal regions. Notching in the duodenal folds could be a strong indication for Crohn's desease. Radiological lesions are not always characteristic, but should be used in combination with endoscopy. Stenosis is an important complication, but fistula formation and pseudodiverticular formation is possible. There is no uniform medical therapy, but the regular anti-inflammatory management for Crohn's disease is most often used. Sometimes surgery is needed.

Management of Crohn's Disease in Adults

“…Uncontrolled series have reported symptomatic improvement for upper GI CD with use of proton pump inhibitors (118) and other systemically active therapies, such as systemic corticosteroids, azathioprine, 6-mercaptopurine, methotrexate, in iximab, adalimumab and certolizumab pegol, are used in a manner similar to their use in patients with moderate to severely active ileal or colonic disease (see below). Similarly, there is no evidence base for recommendations regarding the treatment of jejunoileitis that is o en complicated by multifocal stricturing with resultant small bowel bacterial overgrowth and other nutritional consequences (119,120) . Rotating antibiotics can be e ective in the treatment of small bowel bacterial overgrowth, and supportive nutritional therapies (see below) are frequently required.…”

Crohn’s disease in the upper gastrointestinal tract. Own experience and review of the literature

“…We identified 7 patients with the diagnosis of CD in the upper gastrointestinal tract, which is 1.04% of the total hospitalizations due to CD. According to the literature, the appearance of CD in the upper gastrointestinal tract is at the level of 0.5-13% [8,9].…”

“…In the clinical view, dysphagia and weight loss were the most typical symptoms in the first case, whereas in the third heartburn and odynophagia were observed. Endoscopy of the upper gastrointestinal tract can reveal the following lesions in the oesophageal region: irregular reddening or aphthous, or swollen folds of the mucous membrane, deep linear ulcerations located in the whole oesophageal mucous (which in fact is extremely rare) and strictures or fistulas [9,17]. Yekebas et al reported a case of oesophageal perforation due to a stricture of the distal oesophagus as the primary manifestation of CD [17].…”

“…According to some authors, if there is a suspicion of CD in the stomach or duodenum, the test for the presence of H. pylori should be performed, because it is one of the most important factors of chronic inflammation [8,9]. The most frequent endoscopic lesions, due to CD in stomach, are located in the antrum and unusually in the corpus and fundus of the stomach [9,19]. Due to differential morphology of the lesions, it is difficult to distinguish them from lesions caused by other factors.…”

“…They may present as reddening, cobblestone appearance of the mucosa, or erosions. The symptoms may mimic peptic ulcerations or gastric cancers [9]. The occurrence of focal or acute gastritis among patients with focal caecum inflammation can suggest the occurrence of CD [20,21].…”