Juan Castano, MD1, Grigoriy Rapoport, MD2, Hussein Al Jobori, MD3, Subrahmanyam Behara, MD4
1University of Texas Rio Grande Valley at Doctors Hospital at Renaissance, Edinburg, TX; 2University of Texas Health Rio Grande Valley, Edinburg, TX; 3University of Texas Rio Grande Valley, McAllen, TX; 4Doctors Hospital at Renaissance, Edinburg, TX
Introduction: Crohn’s disease (CD) is a chronic relapsing inflammatory disease which mainly affects the gastrointestinal tract. Although about 30–50% of these patients develop proximal disease, only about 0.5–4% of patients have clinically significant disease involving the stomach and/or duodenum. We present a case of isolated duodenal CD presenting as gastric outlet obstruction (GOO) requiring gastrectomy.
Case Description/Methods: An 18-year-old woman without medical history presented to clinic with a 4-year history of postprandial abdominal pain, nausea, nonbloody emesis, decreased appetite, and unintentional weight loss. EGD demonstrated pyloric stenosis confirmed with upper GI series. Due to persistent symptoms with worsening weight loss on follow up, patient underwent repeat EGD that showed pyloric stenosis and erosive duodenitis. Duodenal biopsy showed active duodenitis with mucosal ulceration and granulation tissue. Pertinent labs were positive for ASCA IgA and ASCA IgG but negative for ANCA. As C-reactive protein was normal, patient was not begun on therapy. One month later, she underwent subtotal gastrectomy with partial small bowel resection with pathology showing marked active and chronic enteritis with ulceration and granulomas consistent with CD. On follow up, patient’s symptoms had resolved and she had largely returned to her baseline weight gaining about 30lbs.
Discussion: Published cases of proximal CD typically present with a several years history of progressively worsening gastritis-like epigastric pain. GOO developed in several cases, however, usually after numerous years. GOO symptoms frequently included bloating, vomiting, postprandial pain, and weight loss with inability to tolerate oral intake similar to our patient. Like other few published cases, our patient’s initial presentation of CD was GOO, though weight loss was quite severe in our patient. To our knowledge, rapidly progressive obstructive symptoms developed in two published cases. Duodenal CD treatment includes medical and endoscopic therapy. Medical therapy includes acid suppression with a proton-pump inhibitor and anti-TNF therapy. Endoscopic dilation may be possible if a stricture is present. Surgical intervention is undertaken when conservative therapy fails which includes resection, bypass, or strictureplasty. Duodenal CD causing GOO poses a diagnostic challenge and often requires a combination of endoscopic, radiological, histologic, and biochemical findings for accurate diagnosis and treatment.
Citation: Juan Castano, MD; Grigoriy Rapoport, MD; Hussein Al Jobori, MD; Subrahmanyam Behara, MD. P2630 - DUODENAL CROHN’S DISEASE PRESENTING AS GASTRIC OUTLET OBSTRUCTION REQUIRING PARTIAL GASTRECTOMY. Program No. P2630. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.