Crohn’s disease with isolated gastric involvement as an example of a rare disease phenotype: a clinical case

Cover Page

Cite item

Abstract

Crohn's disease (CD), along with ulcerative colitis, is one of the predominant nosological forms of inflammatory bowel diseases. In CD, any part of the gastrointestinal tract can be affected; however, the process is commonly associated with terminal ileum or colon involvement. CD cases with isolated or mixed involvement of upper gastrointestinal tract (esophagus, stomach, and duodenum) are rare and least studied types of the disease. In isolated stomach involvement, the complaints are non-specific and include epigastric pain, gastric dyspepsia, early satiety, decreased appetite, and nausea. Isolated CD of upper gastrointestinal tract can be diagnosed after comprehensive work-up and always requires a high diagnostic level, including clinical, endoscopic and morphological one. We present a clinical case of CD with isolated stomach involvement in a 62-year-old woman. The diagnosis was confirmed by the histopathological findings of an epithelioid cell granuloma in the gastric antrum. Treatment with systemic corticosteroids reduced the disease clinical activity and improved the histological characteristics of the gastric biopsy sampled obtained by endoscopy. In this clinical case, there were specific macroscopic gastric lesions found at endoscopy in CD patients with upper gastrointestinal tract involvement, which is characterized by thickened longitudinal folding and linear grooves. This type of lesion has been described in the literature as “bamboo joint-like appearance”.

Conclusion: Comprehensive assessment of clinical manifestations, endoscopic and histopathological specific features is crucial for the timely diagnosis and treatment of inflammatory bowel diseases.

About the authors

E. B. Avalueva

North-Western State Medical University named after I.I. Mechnikov;
Diagnostic Center with Clinic

Author for correspondence.
Email: avalueva@mail.ru
ORCID iD: 0000-0001-6011-0998

Elena B. Avalueva – MD, PhD, Professor, Chair of Propaedeutics of Internal Diseases, Gastroenterology and Dietetics named after S.M. Ryss North-Western State Medical University named after I.I. Mechnikov; Gastroenterologist, Department of Therapy and General Physician Practice Diagnostic Center with Clinic

47–24 Piskarevsky prospekt, Saint Petersburg, 195067, 

41 Kirochnaya ul., Saint Petersburg, 191015, 

3 Morskoy prospekt, Saint Petersburg, 197110


Russian Federation

I. G. Bakulin

North-Western State Medical University named after I.I. Mechnikov

Email: fake@neicon.ru
ORCID iD: 0000-0002-6151-2021

Igor G. Bakulin – MD, PhD, Professor, Head of the Chair of Propaedeutics of Internal Diseases, Gastroenterology and Dietetics named after S.M. Ryss

41 Kirochnaya ul., Saint Petersburg, 191015

Russian Federation

S. I. Sitkin

North-Western State Medical University named after I.I. Mechnikov;
State Research Institute of Highly Pure Biopreparations;
Almazov National Medical Research Centre

Email: fake@neicon.ru
ORCID iD: 0000-0003-0331-0963

Stanislav I. Sitkin – Dr. med., PhD, Associate Professor, Chair of Propaedeutics of Internal Diseases, Gastroenterology and Dietetics named after S.M. Ryss North-Western State Medical University named after I.I. Mechnikov; Leading Research Fellow, Laboratory of Microbiology State Research Institute of Highly Pure Biopreparations, Head of Epigenetics and Metagenomics Research Group, Institute of Perinatology and Pediatrics Almazov National Medical Research Centre

41 Kirochnaya ul., Saint Petersburg, 191015, 

7 Pudozhskaya ul., Saint Petersburg, 197110, 

2 Akkuratova ul., Saint Petersburg, 197341

Russian Federation

S. L. Vorobyev

National Center for Clinical Morphological Diagnostics

Email: fake@neicon.ru

Sergey L. Vorobyev – MD, PhD, Director

8/2A–6H Oleko Dundicha ul., Saint Petersburg, 192283

Russian Federation

I. A. Belyakov

National Center for Clinical Morphological Diagnostics

Email: fake@neicon.ru

Il'ya A. Belyakov – MD, Pathologist, Head of Department of Pathology

8/2A–6H Oleko Dundicha ul., Saint Petersburg, 192283

Russian Federation

N. A. Trushnikova

Diagnostic Center with Clinic

Email: fake@neicon.ru

Nina A. Trushnikova – MD, PhD, Head of Department of Endoscopy

3 Morskoy prospekt, Saint Petersburg, 197110

Russian Federation

Yu. S. Karpeeva

Diagnostic Center with Clinic

Email: fake@neicon.ru

Yulia S. Karpeeva – MD, PhD, Physician, Department of Therapy and General Physician Practice

3 Morskoy prospekt, Saint Petersburg, 197110

Russian Federation

References

  1. Loftus EV Jr, Schoenfeld P, Sandborn WJ. The epidemiology and natural history of Crohn's disease in population-based patient cohorts from North America: a systematic review. Aliment Pharmacol Ther. 2002;16(1): 51–60. doi: 10.1046/j.1365-2036.2002.01140.x.
  2. Loftus EV Jr. Update on the Incidence and Prevalence of Inflammatory Bowel Disease in the United States. Gastroenterol Hepatol (N Y). 2016;12(11): 704–7.
  3. Comfort MW, Weber HM, Baggenstoss AH, Kiely WF. Nonspecific granulomatous inflammation of the stomach and duodenum; its relation to regional enteritis. Am J Med Sci. 1950;220(6): 616–32. doi: 10.1097/00000441195022060-00004.
  4. Crohn BB, Ginzburg L, Oppenheimer GD. Landmark article Oct 15, 1932. Regional ileitis. A pathological and clinical entity. By Burril B. Crohn, Leon Ginzburg, and Gordon D. Oppenheimer. JAMA. 1984;251(1): 73–9. doi: 10.1001/jama.251.1.73.
  5. Kefalas CH. Gastroduodenal Crohn's disease. Proc (Bayl Univ Med Cent). 2003;16(2): 147–51. doi: 10.1080/08998280.2003.11927896.
  6. Ingle SB, Adgaonkar BD, Jamadar NP, Siddiqui S, Hinge CR. Crohn's disease with gastroduodenal involvement: Diagnostic approach. World J Clin Cases. 2015;3(6): 479–83. doi: 10.12998/wjcc.v3.i6.479.
  7. Freeman HJ. Application of the Vienna Classification for Crohn's disease to a single clinician database of 877 patients. Can J Gastroenterol. 2001;15(2): 89–93. doi: 10.1155/2001/426968.
  8. Freeman HJ. Application of the Montreal classification for Crohn's disease to a single clinician database of 1015 patients. Can J Gastroenterol. 2007;21(6): 363–6. doi: 10.1155/2007/951526.
  9. Goldstein NS, Amin M. Upper Gastrointestinal Tract in Inflammatory Bowel Disease. Surg Pathol Clin. 2010;3(2): 349–59. doi: 10.1016/j.path.2010.05.004.
  10. Ando T, Nobata K, Watanabe O, Kusugami K, Maeda O, Ishiguro K, Ohmiya N, Niwa Y, Goto H. Abnormalities in the upper gastrointestinal tract in inflammatory bowel disease. Inflammopharmacology. 2007;15(3): 101–4. doi: 10.1007/s10787-006-0735-1.
  11. Lazarev M, Huang C, Bitton A, Cho JH, Duerr RH, McGovern DP, Proctor DD, Regueiro M, Rioux JD, Schumm PP, Taylor KD, Silverberg MS, Steinhart AH, Hutfless S, Brant SR. Relationship between proximal Crohn's disease location and disease behavior and surgery: a cross-sectional study of the IBD Genetics Consortium. Am J Gastroenterol. 2013;108(1): 106–12. doi: 10.1038/ajg.2012.389.
  12. Annunziata ML, Caviglia R, Papparella LG, Cicala M. Upper gastrointestinal involvement of Crohn's disease: a prospective study on the role of upper endoscopy in the diagnostic work-up. Dig Dis Sci. 2012;57(6): 1618–23. doi: 10.1007/s10620-012-2072-0.
  13. Sakuraba A, Iwao Y, Matsuoka K, Naganuma M, Ogata H, Kanai T, Hibi T. Endoscopic and pathologic changes of the upper gastrointestinal tract in Crohn's disease. Biomed Res Int. 2014;2014:610767. doi: 10.1155/2014/610767.
  14. Horjus Talabur Horje CS, Meijer J, Rovers L, van Lochem EG, Groenen MJ, Wahab PJ. Prevalence of Upper Gastrointestinal Lesions at Primary Diagnosis in Adults with Inflammatory Bowel Disease. Inflamm Bowel Dis. 2016;22(8): 1896– 901. doi: 10.1097/MIB.0000000000000786.
  15. Goodhand J, Dawson R, Hefferon M, Tshuma N, Swanson G, Wahed M, Croft NM, Lindsay JO. Inflammatory bowel disease in young people: the case for transitional clinics. Inflamm Bowel Dis. 2010;16(6): 947–52. doi: 10.1002/ibd.21145.
  16. Danese S, Sans M, Fiocchi C. Inflammatory bowel disease: the role of environmental factors. Autoimmun Rev. 2004;3(5): 394–400. doi: 10.1016/j.autrev.2004.03.002.
  17. Gianchecchi E, Fierabracci A. Recent Advances on Microbiota Involvement in the Pathogenesis of Autoimmunity. Int J Mol Sci. 2019;20(2). pii: E283. doi: 10.3390/ijms20020283.
  18. Cary ER, Tremaine WJ, Banks PM, Nagorney DM. Isolated Crohn's disease of the stomach. Mayo Clin Proc. 1989;64(7): 776–9. doi: 10.1016/s0025-6196(12)61750-9.
  19. Ueno F, Matsui T, Matsumoto T, Matsuoka K, Watanabe M, Hibi T; Guidelines Project Group of the Research Group of Intractable Inflammatory Bowel Disease subsidized by the Ministry of Health, Labour and Welfare of Japan and the Guidelines Committee of the Japanese Society of Gastroenterology. Evidence-based clinical practice guidelines for Crohn's disease, integrated with formal consensus of experts in Japan. J Gastroenterol. 2013;48(1): 31–72. doi: 10.1007/s00535-012-0673-1.
  20. Nugent FW, Richmond M, Park SK. Crohn's disease of the duodenum. Gut. 1977;18(2): 115–20. doi: 10.1136/gut.18.2.115.
  21. Gray RR, St Louis EL, Grosman H. Crohn's disease involving the proximal stomach. Gastrointest Radiol. 1985;10(1): 43–5. doi: 10.1007/bf01893068.
  22. Banerjee S, Peppercorn MA. Inflammatory bowel disease. Medical therapy of specific clinical presentations. Gastroenterol Clin North Am. 2002;31(1): 185–202, x. doi: 10.1016/s0889-8553(01)00012-7.
  23. Pimentel AM, Rocha R, Santana GO. Crohn's disease of esophagus, stomach and duodenum. World J Gastrointest Pharmacol Ther. 2019;10(2): 35–49. doi: 10.4292/wjgpt.v10.i2.35.
  24. Ingle SB, Hinge CR, Dakhure S, Bhosale SS. Isolated gastric Crohn's disease. World J Clin Cases. 2013;1(2): 71–3. doi: 10.12998/wjcc.v1.i2.71.
  25. Inayat F, Ullah W, Hussain Q, Shafique K. Crohn's disease presenting as gastric outlet obstruction: a therapeutic challenge? BMJ Case Rep. 2017;2017. pii: bcr-2016-218181. doi: 10.1136/bcr-2016-218181.
  26. van Hogezand RA, Witte AM, Veenendaal RA, Wagtmans MJ, Lamers CB. Proximal Crohn's disease: review of the clinicopathologic features and therapy. Inflamm Bowel Dis. 2001;7(4): 328–37. doi: 10.1097/00054725200111000-00010.
  27. Gomollon F, Dignass A, Annese V, Tilg H, Van Assche G, Lindsay JO, Peyrin-Biroulet L, Cullen GJ, Daperno M, Kucharzik T, Rieder F, Almer S, Armuzzi A, Harbord M, Langhorst J, Sans M, Chowers Y, Fiorino G, Juillerat P, Mantzaris GJ, Rizzello F, Vavricka S, Gionchetti P; ECCO. 3rd European Evidence-based Consensus on the Diagnosis and Management of Crohn's Disease 2016: Part 1: Diagnosis and Medical Management. J Crohns Colitis. 2017;11(1): 3–25. doi: 10.1093/ecco-jcc/jjw168.
  28. Lichtenstein GR, Loftus EV, Isaacs KL, Regueiro MD, Gerson LB, Sands BE. ACG Clinical Guideline: Management of Crohn's Disease in Adults. Am J Gastroenterol. 2018;113(4): 481– 517. doi: 10.1038/ajg.2018.27.
  29. Dambha F, Tanner J, Carroll N. Diagnostic imaging in Crohn's disease: what is the new gold standard? Best Pract Res Clin Gastroenterol. 2014;28(3): 421–36. doi: 10.1016/j.bpg.2014.04.010.
  30. Aggarwal SN, Cavanagh Y, Wang L, Akmal A, Grossman MA. Upper Gastrointestinal Crohn's Disease: Literature Review and Case Presentation. Case Rep Gastrointest Med. 2019;2019:2708909. doi: 10.1155/2019/2708909.
  31. Nomura Y, Moriichi K, Fujiya M, Okumura T. The endoscopic findings of the upper gastrointestinal tract in patients with Crohn's disease. Clin J Gastroenterol. 2017;10(4): 289–96. doi: 10.1007/s12328-017-0759-7.
  32. Schwartzberg DM, Brandstetter S, Grucela AL. Crohn's Disease of the Esophagus, Duodenum, and Stomach. Clin Colon Rectal Surg. 2019;32(4): 231–42. doi: 10.1055/s-00391683850.
  33. Yokota K, Saito Y, Einami K, Ayabe T, Shibata Y, Tanabe H, Watari J, Ohtsubo C, Miyokawa N, Kohgo Y. A bamboo joint-like appearance of the gastric body and cardia: possible association with Crohn's disease. Gastrointest Endosc. 1997;46(3): 268–72. doi: 10.1016/s00165107(97)70100-7.
  34. Hashiguchi K, Takeshima F, Akazawa Y, Matsushima K, Minami H, Yamaguchi N, Shiozawa K, Ohnita K, Ichikawa T, Isomoto H, Nakao K. Bamboo joint-like appearance of the stomach: a stable endoscopic landmark for Crohn's disease regardless of anti-tumor necrosis factor alpha treatment. Med Sci Monit. 2014;20:1918–24. doi: 10.12659/MSM.891060.
  35. Decker GA, Loftus EV Jr, Pasha TM, Tremaine WJ, Sandborn WJ. Crohn's disease of the esophagus: clinical features and outcomes. Inflamm Bowel Dis. 2001;7(2): 113–9. doi: 10.1097/00054725-200105000-00006.
  36. Montgomery EA, Voltaggio L. Biopsy interpretation of the gastrointestinal tract mucosa. Vol. 1: Non-neoplastic. 3rd ed. Wolters Kluwer; 2018. 320 p.
  37. Song DJ, Whang IS, Choi HW, Jeong CY, Jung SH. Crohn's disease confined to the duodenum: A case report. World J Clin Cases. 2016;4(6): 146–50. doi: 10.12998/wjcc.v4.i6.146.
  38. Alcantara M, Rodriguez R, Potenciano JL, Carrobles JL, Munoz C, Gomez R. Endoscopic and bioptic findings in the upper gastrointestinal tract in patients with Crohn's disease. Endoscopy. 1993;25(4): 282–6. doi: 10.1055/s-20071010315.
  39. De Felice KM, Katzka DA, Raffals LE. Crohn's Disease of the Esophagus: Clinical Features and Treatment Outcomes in the Biologic Era. Inflamm Bowel Dis. 2015;21(9): 2106–13. doi: 10.1097/MIB.0000000000000469.
  40. Wagtmans MJ, Verspaget HW, Lamers CB, van Hogezand RA. Clinical aspects of Crohn's disease of the upper gastrointestinal tract: a comparison with distal Crohn's disease. Am J Gastroenterol. 1997;92(9): 1467–71.
  41. Korelitz B, Waye JD, Kreuning J, Sommers SC, Fein HD, Beeber J, Gelberg BJ. Crohn's disease in endoscopic biopsies of the gastric antrum and duodenum. Am J Gastroenterol. 1981;76(2): 103–9.
  42. Miehsler W, Puspok A, Oberhuber T, Vogelsang H. Impact of different therapeutic regimens on the outcome of patients with Crohn's disease of the upper gastrointestinal tract. Inflamm Bowel Dis. 2001;7(2): 99–105. doi: 10.1097/00054725-20010500000004.
  43. Lahner E, Carabotti M, Annibale B. Treatment of Helicobacter pylori infection in atrophic gastritis. World J Gastroenterol. 2018;24(22): 2373–80. doi: 10.3748/wjg.v24.i22.2373.
  44. Grubel P, Choi Y, Schneider D, Knox TA, Cave DR. Severe isolated Crohn's-like disease of the gastroduodenal tract. Dig Dis Sci. 2003;48(7): 1360–5. doi: 10.1023/a:1024123613071.
  45. Lewis JD, Abreu MT. Diet as a Trigger or Therapy for Inflammatory Bowel Diseases. Gastroenterology. 2017;152(2): 398–414.e6. doi: 10.1053/j.gastro.2016.10.019.
  46. Nugent FW, Roy MA. Duodenal Crohn's disease: an analysis of 89 cases. Am J Gastroenterol. 1989;84(3): 249–54.

Supplementary files

There are no supplementary files to display.


Copyright (c) 2019 Avalueva E.B., Bakulin I.G., Sitkin S.I., Vorobyev S.L., Belyakov I.A., Trushnikova N.A., Karpeeva Y.S.

Creative Commons License
This work is licensed under a Creative Commons Attribution 4.0 International License.

This website uses cookies

You consent to our cookies if you continue to use our website.

About Cookies