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Dourado J, Wignakumar A, Emile SH, Rogers P, Weiss BP, Khan SM, Aeschbacher P, Wexner SD. Bypass is associated with lower treatment failure than stricturoplasty in duodenal Crohn's disease: a systematic review with pairwise and network meta-analyses. J Gastrointest Surg 2025; 29:102041. [PMID: 40154834 DOI: 10.1016/j.gassur.2025.102041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2025] [Revised: 03/14/2025] [Accepted: 03/22/2025] [Indexed: 04/01/2025]
Abstract
BACKGROUND Crohn's disease (CD) of the duodenum is uncommon, and the goal of treatment is often avoidance of surgery. However, as many as one-third of patients with CD will eventually require surgery for their disease. This study aimed to compare the outcomes and safety of surgical treatments of duodenal CD. METHODS In this meta-analysis, a search was conducted for studies that reported outcomes of surgical treatment of duodenal CD. The primary outcome was treatment failure. The secondary outcomes were postoperative complications and reoperation rate. RESULTS A total of 10 studies that included 325 patients with predominately stricturing duodenal CD published between 1970 and 2023 were included. Bypass was the surgical treatment for 155 patients (68.6%), followed by stricturoplasty (21.7%) and resection (8.4%). Pairwise meta-analyses revealed that the only significant finding was a lower rate of treatment failure in favor of bypass compared with stricturoplasty (odds ratio [OR], 0.41 [95% CI, 0.18-0.95]; P =.038), with similar odds of complications and reoperation among the 3 operations. In the network meta-analysis, bypass ranked the best with the lowest failure, complication, and reoperation rates. Stricturoplasty had a significantly higher rate of failure than bypass (OR, 2.51 [95% CI, 1.10-5.27]; P =.028). CONCLUSION Among the 3 procedures, surgical bypass ranked the best with the lowest failure, complications, and reoperation rates. Although bypass was associated with a lower failure rate than stricturoplasty, both procedures were associated with similar complication and reoperation rates. Based upon this review, surgical bypass is a safe and effective option for the treatment of stricturing duodenal CD.
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Affiliation(s)
- Justin Dourado
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL, United States
| | - Anjelli Wignakumar
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL, United States
| | - Sameh Hany Emile
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL, United States; Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura, Egypt
| | - Peter Rogers
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL, United States
| | - Brett P Weiss
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL, United States
| | - Sualeh Muslim Khan
- Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Pauline Aeschbacher
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL, United States.
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Amadu M, Soldera J. Duodenal Crohn's disease: Case report and systematic review. World J Methodol 2024; 14:88619. [PMID: 38577197 PMCID: PMC10989410 DOI: 10.5662/wjm.v14.i1.88619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 12/16/2023] [Accepted: 01/18/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND Inflammatory bowel disease, including ulcerative colitis, microscopic colitis, and Crohn's disease (CD), has a global impact. This review focuses on duodenal CD (DCD), a rare subtype affecting the duodenum. DCD's rarity and asymptomatic nature create diagnostic challenges, impacting prognosis and patient well-being. Delayed diagnosis can worsen DCD outcomes. AIM To report a rare case of DCD and to discuss the diagnostic challenges and its implications on prognosis. METHODS A systematic literature search, following the PRISMA statement, was conducted. Relevant studies were identified and analysed using specific Medical Subject Terms (MeSH) from PubMed/MEDLINE, American Journal of Gastroenterology, and the University of South Wales database. Data collection included information from radiology scans, endoscopy procedures, biopsies, and histopathology results. RESULTS The review considered 8 case reports and 1 observational study, involving 44 participants diagnosed with DCD, some of whom developed complications due to delayed diagnosis. Various diagnostic methods were employed, as there is no gold standard workup for DCD. Radiology scans [magnetic resonance imaging (MRI), computed tomography (CT), and upper gastrointestinal X-ray], endoscopy procedures (colonoscopy and esophagogastroduodenoscopy), biopsies, and clinical suspicions were utilized. CONCLUSION This review discusses DCD diagnosis challenges and the roles of CT, MRI, and fluoroscopy. It notes their limitations and compares findings with endoscopy and histopathology studies. Further research is needed to improve diagnosis, emphasizing scan interpretation, endoscopy procedures, and biopsies, especially in high-risk patients during routine endoscopy.
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Affiliation(s)
- Muniratu Amadu
- Department of Gastroenterology, University of South Wales, Cardiff CF37 1DL, United Kingdom
| | - Jonathan Soldera
- Department of Gastroenterology, University of South Wales, Cardiff CF37 1DL, United Kingdom
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Yang LC, Wu GT, Wu Q, Peng LX, Zhang YW, Yao BJ, Liu GL, Yuan LW. Surgical management of duodenal Crohn's disease. World J Gastrointest Surg 2023; 15:1159-1168. [PMID: 37405094 PMCID: PMC10315127 DOI: 10.4240/wjgs.v15.i6.1159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 03/24/2023] [Accepted: 04/28/2023] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND The case of Crohn's disease involving the duodenum is rare, and its surgical management requires a thorough understanding.
AIM To investigate the surgical management of duodenal Crohn’s disease.
METHODS We systematically reviewed patients diagnosed with duodenal Crohn's disease who underwent surgery in the Department of Geriatrics Surgery of the Second Xiangya Hospital of Central South University from January 1, 2004, to August 31, 2022. The general information, surgical procedures, prognosis, and other information of these patients were collected and summarized.
RESULTS A total of 16 patients were diagnosed with duodenal Crohn’s disease, where 6 cases had primary duodenal Crohn’s disease, and 10 had secondary duodenal Crohn’s disease. Among patients with primary disease, 5 underwent duodenal bypass and gastrojejunostomy, and 1 received pancreaticoduodenectomy. Among those with a secondary disease, 6 underwent closure of duodenal defect and colectomy, 3 received duodenal lesion exclusion and right hemicolectomy, and 1 underwent duodenal lesion exclusion and double-lumen ileostomy.
CONCLUSION Crohn's disease involving the duodenum is a rare condition. Different surgical management should be applied for patients with Crohn's disease presenting with different clinical manifestations.
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Affiliation(s)
- Li-Chao Yang
- Department of Geriatric Surgery, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan Province, China
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan Province, China
| | - Guo-Tao Wu
- Department of General Surgery, The Seventh Affiliated Hospital, University of South China, Changsha 410119, Hunan Province, China
| | - Qiang Wu
- Department of Geriatric Surgery, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan Province, China
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan Province, China
| | - Liang-Xin Peng
- Department of Geriatric Surgery, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan Province, China
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan Province, China
| | - Ya-Wei Zhang
- Department of Geriatric Surgery, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan Province, China
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan Province, China
| | - Bao-Jia Yao
- Department of Geriatric Surgery, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan Province, China
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan Province, China
| | - Gang-Lei Liu
- Department of Geriatric Surgery, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan Province, China
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan Province, China
| | - Lian-Wen Yuan
- Department of Geriatric Surgery, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan Province, China
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan Province, China
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Johnson LN, Moran SK, Bhargava P, Revels JW, Moshiri M, Rohrmann CA, Mansoori B. Fluoroscopic Evaluation of Duodenal Diseases. Radiographics 2022; 42:397-416. [PMID: 35179986 DOI: 10.1148/rg.210165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The duodenum can be affected by a variety of abnormalities because of its development during embryogenesis and its dual intra- and retroperitoneal location. If small bowel embryogenesis is disturbed, congenital errors occur. Although some congenital variants may be asymptomatic and inconsequential to the patient, other anomalies can result in life-threatening emergencies such as malrotation, leading to midgut volvulus. Many infectious processes affect the duodenum, including duodenal ulcers and opportunistic infection in patients with HIV/AIDS or Crohn disease. Small bowel malignancies are uncommon but important to recognize, because the duodenum can be involved in polyposis syndromes or the development of primary adenocarcinoma, neuroendocrine tumors, lymphoma, and metastasis. Although endoscopy is currently the most used diagnostic method to assess the lumen of the upper gastrointestinal tract, fluoroscopy is a valuable adjunct technique and the study of choice for many diseases, specifically those for which anatomic and functional information is required. Fluoroscopy is also commonly used postoperatively to assess for complications such as obstruction and extraluminal leaks. Compared with endoscopy, fluoroscopy is an inexpensive and noninvasive technique that provides salient anatomic information and allows delineation of the duodenal mucosa and assessment of real-time duodenal motility. The authors examine the broad spectrum of conditions that can involve the duodenum, including congenital, infectious, inflammatory, and neoplastic abnormalities, and review their typical appearances at fluoroscopy. Online supplemental material is available for this article. ©RSNA, 2022.
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Affiliation(s)
- Lisa N Johnson
- From the Department of Radiology, University of Washington, 1959 NE Pacific St, Seattle, WA 98195-7115 (L.N.J., S.K.M., P.B., M.M., C.A.R., B.M.); Department of Radiology, University of New Mexico, Albuquerque, NM (J.W.R.); and Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.)
| | - Shamus K Moran
- From the Department of Radiology, University of Washington, 1959 NE Pacific St, Seattle, WA 98195-7115 (L.N.J., S.K.M., P.B., M.M., C.A.R., B.M.); Department of Radiology, University of New Mexico, Albuquerque, NM (J.W.R.); and Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.)
| | - Puneet Bhargava
- From the Department of Radiology, University of Washington, 1959 NE Pacific St, Seattle, WA 98195-7115 (L.N.J., S.K.M., P.B., M.M., C.A.R., B.M.); Department of Radiology, University of New Mexico, Albuquerque, NM (J.W.R.); and Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.)
| | - Jonathan W Revels
- From the Department of Radiology, University of Washington, 1959 NE Pacific St, Seattle, WA 98195-7115 (L.N.J., S.K.M., P.B., M.M., C.A.R., B.M.); Department of Radiology, University of New Mexico, Albuquerque, NM (J.W.R.); and Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.)
| | - Mariam Moshiri
- From the Department of Radiology, University of Washington, 1959 NE Pacific St, Seattle, WA 98195-7115 (L.N.J., S.K.M., P.B., M.M., C.A.R., B.M.); Department of Radiology, University of New Mexico, Albuquerque, NM (J.W.R.); and Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.)
| | - Charles A Rohrmann
- From the Department of Radiology, University of Washington, 1959 NE Pacific St, Seattle, WA 98195-7115 (L.N.J., S.K.M., P.B., M.M., C.A.R., B.M.); Department of Radiology, University of New Mexico, Albuquerque, NM (J.W.R.); and Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.)
| | - Bahar Mansoori
- From the Department of Radiology, University of Washington, 1959 NE Pacific St, Seattle, WA 98195-7115 (L.N.J., S.K.M., P.B., M.M., C.A.R., B.M.); Department of Radiology, University of New Mexico, Albuquerque, NM (J.W.R.); and Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.)
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Kővári B, Pai RK. Upper Gastrointestinal Tract Involvement in Inflammatory Bowel Diseases: Histologic Clues and Pitfalls. Adv Anat Pathol 2022; 29:2-14. [PMID: 34310370 PMCID: PMC8663524 DOI: 10.1097/pap.0000000000000311] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The upper gastrointestinal (UGI) manifestations of inflammatory bowel diseases (IBDs) are frequently obscured by classic ileal and colonic symptoms and are reported to involve only 0.5% to 4% of adult patients. However, because of the improvement of endoscopic techniques and the growing use of esophagogastroduodenososcopy with biopsy, both asymptomatic and clinically significant esophageal, gastric, and duodenal manifestations are increasingly recognized. The UGI involvement in IBD was historically synonymous with Crohn's disease (CD), but the doctrine of ulcerative colitis (UC) being limited to the colon has been challenged, and UC-related gastroduodenal lesions have been reported. The diagnosis of UGI IBD should ideally rely on a combination of the clinical history, endoscopic picture, and histologic features. Although endoscopic changes such as aphthoid or longitudinal ulcers and bamboo-joint-like pattern are suggestive of CD, histologic evaluation increases the sensitivity of the IBD diagnosis since histologic alterations may be present in endoscopically unremarkable mucosa. Conversely, in many cases, the histologic findings are nonspecific, and the knowledge of clinical history is vital for reaching an accurate diagnosis. The presence of epithelioid granuloma is highly suggestive of CD but is present in a minority of CD cases; thus, pathologists should be aware of how to diagnose UGI IBD in the absence of granulomata. This article reviews the most important clinical, endoscopic, and histologic features of IBD-associated esophagitis, gastritis, and duodenitis, as well as the IBD-related manifestations in the biliary tract and the postcolectomy setting.
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Affiliation(s)
- Bence Kővári
- Department of Pathology, Henry Lee Moffitt Cancer Center and Research Institute, Tampa, FL
- Department of Pathology, University of Szeged and Albert Szent-Györgyi Health Center, Szeged, Hungary
| | - Rish K. Pai
- Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, Scottsdale, AZ
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Pimentel AM, de Freitas LAR, Cruz RDCR, Silva INDN, Andrade LD, Marques PN, Braga JC, Fortes FML, Brito KRM, Fontes JAM, Almeida NP, Surlo VC, Rocha R, Lyra AC, Santana GO. Endoscopic and Histopathological Findings of the Esophagus, Stomach, and Duodenum in Patients with Crohn's Disease from a Reference Center in Bahia, Brazil. Clin Pract 2021; 11:374-385. [PMID: 34203639 PMCID: PMC8293082 DOI: 10.3390/clinpract11020052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/12/2021] [Accepted: 06/09/2021] [Indexed: 02/05/2023] Open
Abstract
(1) The aim of the present study was to describe the endoscopic and histopathological findings in the esophagus, stomach, and duodenum in patients with Crohn's disease. (2) Methods: This was a cross-sectional study that included patients receiving treatment from the inflammatory bowel disease outpatient clinic. Esophagogastroduodenoscopies with biopsies of the stomach and proximal duodenum were performed. Presence of Helicobacter pylori bacteria was assessed by Giemsa staining. (3) Results: We included 58 patients. Erosive esophagitis was identified in 25 patients (43.1%), gastritis was diagnosed in 32 patients (55.2%) and erosive duodenitis was found in eight (13.8%). The most frequent histopathological finding in the H. pylori-positive group was increased inflammatory activity in the gastric body and antrum, with a predominance of mononuclear and polymorphonuclear cells. In turn, the most frequent finding in the H. pylori-negative group was chronic inflammation with predominance of mononuclear cells. Focally enhanced gastritis was identified in four patients (6.9%), all of whom were negative for H. pylori. Granulomas were not observed. H. pylori infection was present in 19 patients (32.8%). (4) Conclusions: Nonspecific endoscopic and histological findings were frequent in patients with Crohn's disease. Focally enhanced gastritis was uncommon and observed only in H. pylori-negative patients. The time from the diagnosis, patient age, and therapy in use may have influenced the nondetection of epithelioid granuloma.
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Affiliation(s)
- Andrea Maia Pimentel
- Medicine and Health Science Postgraduate Program, Federal University of Bahia, Salvador 40026-010, Brazil; (A.M.P.); (A.C.L.)
| | | | - Rita de Cássia Reis Cruz
- Gastroenterology Unit, Hospital Geral Roberto Santos, Salvador 45675-000, Brazil; (R.d.C.R.C.); (F.M.L.F.); (K.R.M.B.); (J.A.M.F.); (N.P.A.); (V.C.S.)
| | - Isaac Neri de Novais Silva
- Department of Life Sciences, Universidade do Estado da Bahia, Salvador 41195-001, Brazil; (I.N.d.N.S.); (P.N.M.); (J.C.B.)
| | | | - Paola Nascimento Marques
- Department of Life Sciences, Universidade do Estado da Bahia, Salvador 41195-001, Brazil; (I.N.d.N.S.); (P.N.M.); (J.C.B.)
| | - Júlia Cordeiro Braga
- Department of Life Sciences, Universidade do Estado da Bahia, Salvador 41195-001, Brazil; (I.N.d.N.S.); (P.N.M.); (J.C.B.)
| | - Flora Maria Lorenzo Fortes
- Gastroenterology Unit, Hospital Geral Roberto Santos, Salvador 45675-000, Brazil; (R.d.C.R.C.); (F.M.L.F.); (K.R.M.B.); (J.A.M.F.); (N.P.A.); (V.C.S.)
| | - Katia Rejane Marques Brito
- Gastroenterology Unit, Hospital Geral Roberto Santos, Salvador 45675-000, Brazil; (R.d.C.R.C.); (F.M.L.F.); (K.R.M.B.); (J.A.M.F.); (N.P.A.); (V.C.S.)
| | - Jaciane Araújo Mota Fontes
- Gastroenterology Unit, Hospital Geral Roberto Santos, Salvador 45675-000, Brazil; (R.d.C.R.C.); (F.M.L.F.); (K.R.M.B.); (J.A.M.F.); (N.P.A.); (V.C.S.)
| | - Neogélia Pereira Almeida
- Gastroenterology Unit, Hospital Geral Roberto Santos, Salvador 45675-000, Brazil; (R.d.C.R.C.); (F.M.L.F.); (K.R.M.B.); (J.A.M.F.); (N.P.A.); (V.C.S.)
| | - Valdiana Cristina Surlo
- Gastroenterology Unit, Hospital Geral Roberto Santos, Salvador 45675-000, Brazil; (R.d.C.R.C.); (F.M.L.F.); (K.R.M.B.); (J.A.M.F.); (N.P.A.); (V.C.S.)
| | - Raquel Rocha
- Department of Sciences of Nutrition, School of Nutrition, Federal University of Bahia, Salvador 41195-00, Brazil;
| | - André Castro Lyra
- Medicine and Health Science Postgraduate Program, Federal University of Bahia, Salvador 40026-010, Brazil; (A.M.P.); (A.C.L.)
| | - Genoile Oliveira Santana
- Medicine and Health Science Postgraduate Program, Federal University of Bahia, Salvador 40026-010, Brazil; (A.M.P.); (A.C.L.)
- Department of Life Sciences, Universidade do Estado da Bahia, Salvador 41195-001, Brazil; (I.N.d.N.S.); (P.N.M.); (J.C.B.)
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Abstract
Although the features of lower gastrointestinal tract inflammation associated with ulcerative colitis and Crohn disease are generally familiar to pathologists, there is less awareness of and familiarity with the manifestations of inflammatory bowel disease in the esophagus, stomach, and duodenum. Nonetheless, their diagnosis has therapeutic and possibly prognostic implications, potentially foretelling severe complications. The recognition that ulcerative colitis can affect gastrointestinal organs proximal to the large intestine and terminal ileum represents a revision of concepts ingrained among generations of physicians. This article reviews the pathologic features and clinical significance of esophagitis, gastritis, and duodenitis associated with inflammatory bowel disease.
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Affiliation(s)
- Noam Harpaz
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, Annenberg Building Room 15-38, 1468 Madison Avenue, New York, NY 10029, USA; Department of Medicine, Icahn School of Medicine at Mount Sinai, Annenberg Building Room 15-38, 1468 Madison Avenue, New York, NY 10029, USA.
| | - Alexandros D Polydorides
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, Annenberg Building Room 15-38, 1468 Madison Avenue, New York, NY 10029, USA; Department of Medicine, Icahn School of Medicine at Mount Sinai, Annenberg Building Room 15-38, 1468 Madison Avenue, New York, NY 10029, USA
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Exploring the neglected segment of the intestine: the duodenum and its pathologies. Pol J Radiol 2020; 85:e230-e244. [PMID: 32612721 PMCID: PMC7315055 DOI: 10.5114/pjr.2020.95477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 03/17/2020] [Indexed: 12/17/2022] Open
Abstract
Herein we reviewed the computed tomography (CT) findings of a spectrum of pathological entities affecting the duodenum. We discuss the CT findings of some congenital, inflammatory, traumatic, and neoplastic pathologies of the duodenum along with the conventional barium studies of selected conditions. Pathologies of this C-shaped intestinal segment, derived from both foregut and midgut, are often overlooked in clinical practice and radiological literature. While congenital anomalies like duplication cysts and diverticula are usually asymptomatic, annular pancreas and malrotation may manifest in the first decade of life. Primary as well as secondary involvement of the duodenum by various disease processes can be evaluated by careful CT technique and proper attention to the duodenum. Among congenital conditions, annular pancreas, duplication cyst, superior mesenteric artery syndrome, midgut volvulus, and diverticula are presented. Duodenal involvement in adenocarcinoma, lymphoma, gastrointestinal stromal tumours, Crohn’s disease, and groove pancreatitis are discussed. Duodenal wall haematoma and traumatic duodenal perforation causing pneumoretroperitoneum in two patients after blunt trauma of the abdomen are also illustrated. CT provides superb anatomic detail and offers high diagnostic specificity for the detection of duodenal pathologies because it allows direct imaging of the intestinal wall, secondary signs of bowel disease within the surrounding mesentery, and abnormal findings in adjacent structures. Primary duodenal malignancies and local extension from adjacent malignancies can be diagnosed by CT reliably. CT also plays a vital role in the diagnosis of traumatic duodenal injury by differentiating between mural haematoma and a duodenal perforation because the latter requires immediate surgical intervention.
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Do P, Andersen J, Patel A, Semrin G, Sifuentes-Dominguez L, Luu P, Gurram B. Augmented ustekinumab dosing is needed to achieve clinical response in patients with anti-TNF refractory pediatric Crohn's disease: a retrospective chart review. F1000Res 2020; 9:316. [PMID: 34504690 PMCID: PMC8408544 DOI: 10.12688/f1000research.22673.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/01/2020] [Indexed: 08/03/2023] Open
Abstract
Background: Ustekinumab is a monoclonal antibody that inhibits interleukins 12 and 23. It is approved for treatment of Crohn's disease (CD) in adults; however, there is a paucity of data regarding its use in pediatric CD. We describe our experience using ustekinumab in anti-TNF refractory CD pediatric patients. Methods: We performed a retrospective chart review on pediatric patients with CD who were started on ustekinumab from January 2016 to November 2018. We collected patient's clinical history, previous treatment history, surgeries related to CD, disease severity, as measured by abbrPCDAI, and endoscopic severity as recorded by SES-CD before and after ustekinumab. Results: We identified 10 patients with CD who were started on ustekinumab due to non-response to currently approved agents. Seven patients needed augmented maintenance dosing every 4-6 weeks to achieve clinical response or remission. Six of these seven patients had therapeutic drug monitoring during the course of treatment, with five patients showing subtherapeutic drug levels of <4.5 μg/mL while on standard maintenance dosing every 8 weeks, and four patients showing therapeutic drug levels of >4.5 μg/mL on augmented dosing interval. The remaining three patients were on standard maintenance dosing for the duration of treatment. Conclusion: In this retrospective chart review, 7 out of 10 patients with anti-TNF refractory pediatric-onset CD required augmented maintenance doses of ustekinumab to achieve clinical response or remission. A prospective study is needed to define appropriate ustekinumab dosing and interval in management of pediatric CD.
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Affiliation(s)
- Phinga Do
- Department of Pediatrics, Children’s Health Medical Center Dallas, Dallas, TX, 75235, USA
| | - John Andersen
- Department of Pediatrics, Children’s Health Medical Center Dallas, Dallas, TX, 75235, USA
- Department of Pediatric Gastroenterology, UT Southwestern Medical Center, Dallas, TX, 75235, USA
| | - Ashish Patel
- Department of Pediatrics, Children’s Health Medical Center Dallas, Dallas, TX, 75235, USA
- Department of Pediatric Gastroenterology, UT Southwestern Medical Center, Dallas, TX, 75235, USA
| | - Gaith Semrin
- Department of Pediatrics, Children’s Health Medical Center Dallas, Dallas, TX, 75235, USA
- Department of Pediatric Gastroenterology, UT Southwestern Medical Center, Dallas, TX, 75235, USA
| | - Luis Sifuentes-Dominguez
- Department of Pediatrics, Children’s Health Medical Center Dallas, Dallas, TX, 75235, USA
- Department of Pediatric Gastroenterology, UT Southwestern Medical Center, Dallas, TX, 75235, USA
| | - Phuong Luu
- Department of Pediatrics, Children’s Health Medical Center Dallas, Dallas, TX, 75235, USA
| | - Bhaskar Gurram
- Department of Pediatrics, Children’s Health Medical Center Dallas, Dallas, TX, 75235, USA
- Department of Pediatric Gastroenterology, UT Southwestern Medical Center, Dallas, TX, 75235, USA
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10
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Do P, Andersen J, Patel A, Semrin G, Sifuentes-Dominguez L, Luu P, Gurram B. Augmented ustekinumab dosing is needed to achieve clinical response in patients with anti-TNF refractory pediatric Crohn's disease: a retrospective chart review. F1000Res 2020; 9:316. [PMID: 34504690 PMCID: PMC8408544 DOI: 10.12688/f1000research.22673.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/07/2021] [Indexed: 01/08/2023] Open
Abstract
Background: Ustekinumab is a monoclonal antibody that inhibits interleukins 12 and 23. It is approved for treatment of Crohn's disease (CD) in adults; however, there is a paucity of data regarding its use in pediatric CD. We describe our experience using ustekinumab in anti-TNF refractory CD pediatric patients. Methods: We performed a retrospective chart review on pediatric patients with CD who were started on ustekinumab from January 2016 to November 2018. We collected patient's clinical history, previous treatment history, surgeries related to CD, disease severity, as measured by abbrPCDAI, and endoscopic severity as recorded by SES-CD before and after ustekinumab. Results: We identified 10 patients with CD who were started on ustekinumab due to non-response to currently approved agents. Seven patients needed augmented maintenance dosing every 4-6 weeks to achieve clinical response or remission. Six of these seven patients had therapeutic drug monitoring during the course of treatment, with five patients showing subtherapeutic drug levels of <4.5 μg/mL while on standard maintenance dosing every 8 weeks, and four patients showing therapeutic drug levels of >4.5 μg/mL on augmented dosing interval. The remaining three patients were on standard maintenance dosing for the duration of treatment. Conclusion: In this retrospective chart review, 7 out of 10 patients with anti-TNF refractory pediatric-onset CD required augmented maintenance doses of ustekinumab to achieve clinical response or remission. A prospective study is needed to define appropriate ustekinumab dosing and interval in management of pediatric CD.
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Affiliation(s)
- Phinga Do
- Department of Pediatrics, Children’s Health Medical Center Dallas, Dallas, TX, 75235, USA
| | - John Andersen
- Department of Pediatrics, Children’s Health Medical Center Dallas, Dallas, TX, 75235, USA
- Department of Pediatric Gastroenterology, UT Southwestern Medical Center, Dallas, TX, 75235, USA
| | - Ashish Patel
- Department of Pediatrics, Children’s Health Medical Center Dallas, Dallas, TX, 75235, USA
- Department of Pediatric Gastroenterology, UT Southwestern Medical Center, Dallas, TX, 75235, USA
| | - Gaith Semrin
- Department of Pediatrics, Children’s Health Medical Center Dallas, Dallas, TX, 75235, USA
- Department of Pediatric Gastroenterology, UT Southwestern Medical Center, Dallas, TX, 75235, USA
| | - Luis Sifuentes-Dominguez
- Department of Pediatrics, Children’s Health Medical Center Dallas, Dallas, TX, 75235, USA
- Department of Pediatric Gastroenterology, UT Southwestern Medical Center, Dallas, TX, 75235, USA
| | - Phuong Luu
- Department of Pediatrics, Children’s Health Medical Center Dallas, Dallas, TX, 75235, USA
| | - Bhaskar Gurram
- Department of Pediatrics, Children’s Health Medical Center Dallas, Dallas, TX, 75235, USA
- Department of Pediatric Gastroenterology, UT Southwestern Medical Center, Dallas, TX, 75235, USA
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11
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Avalueva EB, Bakulin IG, Sitkin SI, Vorobyev SL, Belyakov IA, Trushnikova NA, Karpeeva YS. Crohn’s disease with isolated gastric involvement as an example of a rare disease phenotype: a clinical case. ALMANAC OF CLINICAL MEDICINE 2019; 47:592-602. [DOI: 10.18786/2072-0505-2019-47-074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
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.
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Affiliation(s)
- E. B. Avalueva
- North-Western State Medical University named after I.I. Mechnikov;
Diagnostic Center with Clinic
| | - I. G. Bakulin
- North-Western State Medical University named after I.I. Mechnikov
| | - 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
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12
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Schwartzberg DM, Brandstetter S, Grucela AL. Crohn's Disease of the Esophagus, Duodenum, and Stomach. Clin Colon Rectal Surg 2019; 32:231-242. [PMID: 31275069 PMCID: PMC6606321 DOI: 10.1055/s-0039-1683850] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Upper gastrointestinal Crohn's is an under-reported, under-recognized phenotype of Crohn's disease. Routine screening in the pediatric population has shown a higher prevalence compared with adults; however, most adult patients remain asymptomatic with respect to upper gastrointestinal Crohn's disease. For the patients who are symptomatic, medical treatment is the first line of management, except for cases of obstruction, perforation, or bleeding. Though most patients respond to medical therapy, mainly steroids, with the addition of immunomodulators and more recently biologics agents, surgical intervention is usually required only for obstructing gastroduodenal disease secondary to strictures. Strictureplasty and bypass are safe operations with comparable morbidity, although bypass has higher rates of dumping syndrome and marginal ulceration in the long term. Rare cases of gastroduodenal fistulous disease from active distal disease may involve the stomach or duodenum, and esophageal Crohn's disease can fistulize to surrounding structures in the mediastinum which may require the highly morbid esophagectomy.
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Affiliation(s)
- David M. Schwartzberg
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Stephen Brandstetter
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Alexis L. Grucela
- Division of Colon and Rectal Surgery, New York University Langone Medical Center, New York, New York
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13
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Pimentel AM, Rocha R, Santana GO. Crohn’s disease of esophagus, stomach and duodenum. World J Gastrointest Pharmacol Ther 2019; 10:35-49. [PMID: 30891327 PMCID: PMC6422852 DOI: 10.4292/wjgpt.v10.i2.35] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 01/31/2019] [Accepted: 02/27/2019] [Indexed: 02/06/2023] Open
Abstract
Crohn’s disease with involvement of the esophagus, stomach and duodenum has a prevalence of 0.5% to 4% in symptomatic adult patients, but some studies have shown that these results may be underestimated, since upper gastrointestinal endoscopy is not performed routinely in the initial evaluation of the disease in adult patients, as it is in the pediatric population. In general, involvement of the upper gastrointestinal tract in Crohn’s disease occurs concomitantly with involvement of the lower gastrointestinal tract. The diagnosis depends on clinical, endoscopic, histological and radiological evaluation. The presence of aphthoid ulcers, longitudinal ulcers, bamboo-joint-like appearance, stenoses and fistulas are endoscopic findings suggestive of the disease, and it is important to exclude the presence of Helicobacter pylori infection. The primary histological findings, which facilitate the diagnosis, are the presence of a chronic inflammatory process with a predominance of lymphoplasmacytic cells and active focal gastritis. The presence of epithelioid granuloma, although less frequent, is highly suggestive of the disease in the absence of chronic granulomatous disease. Treatment should include the use of proton pump inhibitors associated with corticosteroids, immunomodulators and biological therapy according to the severity of the disease.
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Affiliation(s)
- Andréa Maia Pimentel
- Programa de Pós graduação em Medicina e Saúde, Universidade Federal da Bahia, Salvador 40110-060, Bahia, Brazil
| | - Raquel Rocha
- Departamento de Ciências da Nutrição, Universidade Federal da Bahia, Salvador 40110-060, Bahia, Brazil
| | - Genoile Oliveira Santana
- Programa de Pós graduação em Medicina e Saúde, Universidade Federal da Bahia, Salvador 40110-060, Bahia, Brazil
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14
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Wu TT. Other Inflammatory Disorders of Duodenum. SURGICAL PATHOLOGY OF NON-NEOPLASTIC GASTROINTESTINAL DISEASES 2019:239-263. [DOI: 10.1007/978-3-030-15573-5_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2025]
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15
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Segal AW. The role of neutrophils in the pathogenesis of Crohn's disease. Eur J Clin Invest 2018; 48 Suppl 2:e12983. [PMID: 29931668 DOI: 10.1111/eci.12983] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 06/19/2018] [Indexed: 12/14/2022]
Abstract
Crohn's disease (CD) is caused by a trigger, almost certainly enteric infection by one of a multitude of organisms that allows faeces access to the tissues, at which stage the response of individuals predisposed to CD is abnormal. In CD the failure of acute inflammation results in the failure to recruit neutrophils to the inflammatory site, as a consequence of which the clearance of bacteria from the tissues is defective. The retained faecal products result in the characteristic chronic granulomatous inflammation and adaptive immune response. Impaired of digestion of bacteria and fungi by CGD neutrophils can result in a similar pathological and clinical picture. The neutrophils in CD are normal and their inadequate accumulation at sites of inflammation generally results from diminished secretion of proinflammatory cytokines by macrophages consequent upon disordered vesicle trafficking.
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16
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Orda R, Sayfan J, Carmeli Y, Scapa E. Surgical Treatment for Crohn's Disease of the Fourth Part of the Duodenum. J R Soc Med 2018; 83:802-3. [PMID: 2269971 PMCID: PMC1292961 DOI: 10.1177/014107689008301218] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- R Orda
- Department of Surgery A, Assaf Harofeh Medical Centre, Sackler Faculty of Medicine, Tel Aviv University, Zerifin, Israel
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17
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Abstract
Symptomatic duodenal Crohn's disease (CD) is an uncommon disease presentation, especially in isolation. The most common duodenal disease phenotype is stricturing disease rather than inflammatory or perforating. Most patients are asymptomatic and are therefore diagnosed incidentally by cross-sectional imaging or endoscopy. Medical management includes proton pump inhibitor therapy and immunosuppressive therapy including corticosteroids, immunomodulatory therapy, and biologic therapy. Symptomatic strictures can often be treated medically or endoscopically, and do not always require surgery. Surgical options include resection with primary anastomosis, bypass with a gastrojejunostomy, and strictureplasty. Treatment recommendations are largely based on limited evidence from small series and expert opinion. Therefore, the optimal treatment algorithm remains largely subjective and undefined.
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Affiliation(s)
- Amy L Lightner
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
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18
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Laube R, Liu K, Schifter M, Yang JL, Suen MK, Leong RW. Oral and upper gastrointestinal Crohn's disease. J Gastroenterol Hepatol 2018; 33:355-364. [PMID: 28708248 DOI: 10.1111/jgh.13866] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 05/31/2017] [Accepted: 07/06/2017] [Indexed: 12/19/2022]
Abstract
Crohn's disease is a heterogeneous, inflammatory condition that can affect any location of the gastrointestinal tract. Proximal gastrointestinal involvement occurs in 0.5-16% of patients, and it is usually diagnosed after recognition of intestinal disease. Symptoms are often mild and nonspecific; however, upper gastrointestinal disease predicts a more severe Crohn's phenotype with a greater frequency of complications such as obstruction and perforation. Gastroscopy and biopsy is the most sensitive diagnostic investigation. There is a paucity of data examining the treatment of this condition. Management principles are similar to those for intestinal disease, commencing with topical therapy where appropriate, progressing to systemic therapy such as glucocorticoids, 5-aminosalicylic acid, immunomodulators, and biologics. Acid suppression therapy has symptomatic but no anti-inflammatory benefit for gastroduodenal and esophageal involvement. Surgical intervention with bypass, strictureplasty, or less frequently, endoscopic balloon dilation may be required for complications or failed medical therapy.
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Affiliation(s)
- Robyn Laube
- Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Ken Liu
- Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Mark Schifter
- Department of Oral Medicine, Westmead Hospital, Sydney, New South Wales, Australia.,Faculty of Dentistry, Sydney University, Sydney, New South Wales, Australia
| | - Jessica L Yang
- Department of Radiology, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Michael K Suen
- Department of Colorectal Surgery, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Rupert W Leong
- Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
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19
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The endoscopic findings of the upper gastrointestinal tract in patients with Crohn's disease. Clin J Gastroenterol 2017; 10:289-296. [PMID: 28695451 DOI: 10.1007/s12328-017-0759-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 06/08/2017] [Indexed: 02/08/2023]
Abstract
Crohn's disease (CD) is a type of chronic inflammatory bowel disease (IBD) associated with ulceration, and the main foci of the inflammation in CD patients are typically the terminal ileum and colon. However, in the upper gastrointestinal tract (GIT), including the esophagus, stomach and duodenum, inflammatory lesions are also detected as well, with a relatively high frequency (30-75%). Recent advances in imaging modalities, including endoscopy, have aided in the diagnosis of CD. Various lesions, including aphtha, erosion, ulcers, bamboo-joint-like appearance and notch-like appearance, are detected in the upper GI of CD patients. Of these lesions, the bamboo-joint-like appearance in the gastric cardiac region and notch-like appearance in the second portion of the duodenum are highly specific for CD, regardless of the disease activity at other sites. These two findings, particularly a bamboo-joint-like appearance, have therefore been considered as potential biomarkers for CD. Although proton pump inhibitors (PPIs) are administered as an initial treatment for upper GIT lesions of CD, the efficacy of this treatment remains controversial. The administration of mesalazine, steroids, immunosuppressant and biologic agents is expected to be effective for treating such lesions.
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20
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Abstract
The cause of Crohn’s disease (CD) has posed a conundrum for at least a century. A large body of work coupled with recent technological advances in genome research have at last started to provide some of the answers. Initially this review seeks to explain and to differentiate between bowel inflammation in the primary immunodeficiencies that generally lead to very early onset diffuse bowel inflammation in humans and in animal models, and the real syndrome of CD. In the latter, a trigger, almost certainly enteric infection by one of a multitude of organisms, allows the faeces access to the tissues, at which stage the response of individuals predisposed to CD is abnormal. Direct investigation of patients’ inflammatory response together with genome-wide association studies (GWAS) and DNA sequencing indicate that in CD the failure of acute inflammation and the clearance of bacteria from the tissues, and from within cells, is defective. The retained faecal products result in the characteristic chronic granulomatous inflammation and adaptive immune response. In this review I will examine the contemporary evidence that has led to this understanding, and look for explanations for the recent dramatic increase in the incidence of this disease.
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21
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Abstract
The cause of Crohn's disease (CD) has posed a conundrum for at least a century. A large body of work coupled with recent technological advances in genome research have at last started to provide some of the answers. Initially this review seeks to explain and to differentiate between bowel inflammation in the primary immunodeficiencies that generally lead to very early onset diffuse bowel inflammation in humans and in animal models, and the real syndrome of CD. In the latter, a trigger, almost certainly enteric infection by one of a multitude of organisms, allows the faeces access to the tissues, at which stage the response of individuals predisposed to CD is abnormal. Direct investigation of patients' inflammatory response together with genome-wide association studies (GWAS) and DNA sequencing indicate that in CD the failure of acute inflammation and the clearance of bacteria from the tissues, and from within cells, is defective. The retained faecal products result in the characteristic chronic granulomatous inflammation and adaptive immune response. In this review I will examine the contemporary evidence that has led to this understanding, and look for explanations for the recent dramatic increase in the incidence of this disease.
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22
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Abstract
Crohn's disease of the foregut is more common than previously recognized, with up to 40% of patients with Crohn's disease in the distal intestine also having evidence of foregut disease. Esophageal disease is best managed medically with proton pump inhibition, steroids, thiopurines, methotrexate, and anti-tumor necrosis factor-α biologic medications. Esophageal strictures are dealt with using endoscopic dilation. Surgery is generally reserved of resistant strictures or esophageal fistulas. Patients with gastroduodenal disease more commonly come to surgery. The most commonly performed operations for gastroduodenal Crohn's disease are intestinal bypass or strictureplasty. The concomitant use of vagotomy remains controversial.
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Affiliation(s)
- Kurt G Davis
- Colon and Rectal Surgery, Department of Surgery, William Beaumont Army Medical Center, 4756 Loma de Plata Drive, El Paso, TX 79934, USA.
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23
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Fujiya M, Sakatani A, Dokoshi T, Tanaka K, Ando K, Ueno N, Gotoh T, Kashima S, Tominaga M, Inaba Y, Ito T, Moriichi K, Tanabe H, Ikuta K, Ohtake T, Yokota K, Watari J, Saitoh Y, Kohgo Y. A Bamboo Joint-Like Appearance is a Characteristic Finding in the Upper Gastrointestinal Tract of Crohn's Disease Patients: A Case-Control Study. Medicine (Baltimore) 2015; 94:e1500. [PMID: 26376393 PMCID: PMC4635807 DOI: 10.1097/md.0000000000001500] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The clinical importance of Crohn's disease (CD)-specific lesions in the upper gastrointestinal tract (upper GIT) has not been sufficiently established. The aim of this case-control study is to investigate the characteristic findings of CD in the upper GIT. In 2740 patients who underwent gastroduodenoscopy at Asahikawa Medical University between April 2011 and December 2012, 81 CD patients, 81 gender- and age-matched non-IBD patients, and 66 ulcerative colitis (UC) patients were investigated in the present study. (1) The diagnostic ability and odds ratio of each endoscopic finding (a bamboo joint-like appearance in the cardia, erosions, and/or ulcers in the antrum, notched signs, and erosions and/or ulcers in the duodenum) were compared between the CD and non-IBD patients or UC patients. (2) The interobserver agreement of the diagnosis based on the endoscopic findings was evaluated by 3 experienced and 3 less-experienced endoscopists. The incidence of detecting a bamboo joint-like appearance, notched signs, and erosions and/or ulcers in the duodenum was significantly higher in the CD patients than in the non-IBD and UC patients. In addition, the diagnostic ability and odds ratio of a bamboo joint-like appearance for CD were higher than those for the other findings. Kendall's coefficients of concordance in the group of experienced and less-experienced endoscopists were relatively high for a bamboo joint-like appearance (0.748 and 0.692, respectively). A cardiac bamboo joint-like appearance is a useful finding for identifying high-risk groups of CD patients using only gastroduodenoscopy.
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Affiliation(s)
- Mikihiro Fujiya
- From the Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University (MF, AS, TD, KT, KA, NU, TG, SK, MT, YI, TI, KM, HT, KI, TO, YK); Department of Gastroenterology, Yoshida Hospital (KY); Division of Upper Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine (JW); and Digestive Disease Center, Asahikawa City Hospital (YS)
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24
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Ingle SB, Adgaonkar BD, Jamadar NP, Siddiqui S, Hinge CR. Crohn’s disease with gastroduodenal involvement: Diagnostic approach. World J Clin Cases 2015; 3:479-483. [PMID: 26090366 PMCID: PMC4468892 DOI: 10.12998/wjcc.v3.i6.479] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 04/14/2015] [Accepted: 04/29/2015] [Indexed: 02/05/2023] Open
Abstract
Crohn’s disease (CD) is a chronic idiopathic inflammatory disease of gastrointestinal tract characterized by segmental and transmural involvement of gastrointestinal tract. Ileocolonic and colonic/anorectal is a most common and account for 40% of cases and involvement of small intestine is about 30%. Isolated involvement of stomach is an extremely unusual presentation of the disease accounting for less than 0.07% of all gastrointestinal CD. To date there are only a few documented case reports of adults with isolated gastric CD and no reports in the pediatric population. The diagnosis is difficult to establish in such cases with atypical presentation. In the absence of any other source of disease and in the presence of nonspecific upper gastrointestinal endoscopy and histological findings, serological testing can play a vital role in the diagnosis of atypical CD. Recent studies have suggested that perinuclear anti-neutrophil cytoplasmic antibody and anti-Saccharomycescervisia antibody may be used as additional diagnostic tools. The effectiveness of infliximab in isolated gastric CD is limited to only a few case reports of adult patients and the long-term outcome is unknown.
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25
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Gupta P, Debi U, Sinha SK, Prasad KK. Upper gastrointestinal barium evaluation of duodenal pathology: A pictorial review. World J Radiol 2014; 6:613-618. [PMID: 25170399 PMCID: PMC4147442 DOI: 10.4329/wjr.v6.i8.613] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Revised: 04/15/2014] [Accepted: 07/18/2014] [Indexed: 02/06/2023] Open
Abstract
Like other parts of the gastrointestinal tract (GIT), duodenum is subject to a variety of lesions both congenital and acquired. However, unlike other parts of the GIT viz. esophagus, rest of the small intestine and large intestine, barium evaluation of duodenal lesions is technically more challenging and hence not frequently reported. With significant advances in computed tomography technology, a thorough evaluation including intraluminal, mural and extramural is feasible in a single non-invasive examination. Notwithstanding, barium evaluation still remains the initial and sometimes the only imaging study in several parts of the world. Hence, a thorough acquaintance with the morphology of various duodenal lesions on upper gastrointestinal barium examination is essential in guiding further evaluation. We reviewed our experience with various common and uncommon barium findings in duodenal abnormalities.
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26
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Raghu Subramanian C, Triadafilopoulos G. The gates of hell: Crohn's disease isolated to the pylorus and ileo-cecal valve. Dig Dis Sci 2014; 59:1108-11. [PMID: 24549833 DOI: 10.1007/s10620-014-3066-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Accepted: 02/05/2014] [Indexed: 12/12/2022]
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27
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Kim YL, Park YS, Park EK, Park DR, Choi GS, Ahn SB, Kim SH, Jo YJ. Refractory duodenal Crohn's disease successfully treated with infliximab. Intest Res 2014; 12:66-9. [PMID: 25349566 PMCID: PMC4204694 DOI: 10.5217/ir.2014.12.1.66] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2012] [Revised: 05/18/2012] [Accepted: 05/26/2012] [Indexed: 01/11/2023] Open
Abstract
Crohn's disease (CD) may involve any part of the gastrointestinal tract, from the mouth to the anus. Approximately >90% of cases occur in the small bowel and colon. Upper gastrointestinal involvement, especially duodenal manifestation, is relatively rare. Therefore, adequate medical treatment for duodenal CD has not yet been established. We report a case of CD with duodenal involvement. A 46-year-old man with Crohn's ileocolitis presented to our hospital with right upper quadrant pain. An endoscopy showed a deep excavated ulcer with deformity at the duodenal bulb, and he was initially treated with azathioprine (1 mg/kg), Pentasa (3.0 g/day), and a proton pump inhibitor for 1 year. However, the deep ulcer did not heal. Therefore, infliximab infusion therapy was initiated, and the duodenal lesion completely resolved on follow-up esophagogastroduodenoscopy. We report a case of duodenal CD that completely resolved following infliximab infusion, with a review of the literature.
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Affiliation(s)
- You Lim Kim
- Department of Internal Medicine, Eulji University School of Medicine, Eulji Medical Center, Seoul, Korea
| | - Young Sook Park
- Department of Internal Medicine, Eulji University School of Medicine, Eulji Medical Center, Seoul, Korea
| | - Eun Kyoung Park
- Department of Internal Medicine, Eulji University School of Medicine, Eulji Medical Center, Seoul, Korea
| | - Dae Rim Park
- Department of Internal Medicine, Eulji University School of Medicine, Eulji Medical Center, Seoul, Korea
| | - Gyu Sik Choi
- Department of Internal Medicine, Eulji University School of Medicine, Eulji Medical Center, Seoul, Korea
| | - Sang Bong Ahn
- Department of Internal Medicine, Eulji University School of Medicine, Eulji Medical Center, Seoul, Korea
| | - Seong Hwan Kim
- Department of Internal Medicine, Eulji University School of Medicine, Eulji Medical Center, Seoul, Korea
| | - Yun Ju Jo
- Department of Internal Medicine, Eulji University School of Medicine, Eulji Medical Center, Seoul, Korea
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28
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Abstract
The relation of Mycobacterium avium ss paratuberculosis (MAP) to Crohn's Disease (CD) and other MAP-associated conditions remains controversial. New data, coupled with the analogous Helicobacter pylori (H. pylori) story, has permitted us to piece together the MAP puzzle and move forward with a more scientific way of treating inflammatory bowel disease, particularly CD. As infection moves centre stage in inflammatory bowel disease, the dated "aberrant reaction" etiology has lost scientific credibility. Now, our growing understanding of MAP-associated diseases demands review and articulation. We focus here on (1) the concept of MAP-associated diseases; (2) causality, Johne Disease, the "aberrant reaction" hypothesis; and (3) responses to published misconceptions questioning MAP as a pathogen in CD.
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29
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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; 57:1618-1623. [PMID: 22350786 DOI: 10.1007/s10620-012-2072-0] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Accepted: 01/23/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND Prevalence of upper gastrointestinal (GI) tract involvement in adult Crohn's disease (CD) has been reported to be very low (0.3-5%). In routine practice, upper endoscopy is recommended only in CD patients with upper GI symptoms. Available data concerning the prevalence of asymptomatic upper GI lesions in CD patients are controversial. The aim of this study was to prospectively evaluate the prevalence of upper GI CD involvement in CD patients, irrespective of upper GI symptoms. METHODS A series of 119 consecutive CD patients underwent clinical assessment, including occurrence and score of upper GI symptoms, and upper endoscopy with biopsy samples for histological assessment and Helicobacter pylori (Hp) infection detection. In an attempt to further recognize the upper GI tract lesions as CD or other form of inflammation, in a subgroup of CD patients, the histological and endoscopic evaluation was repeated following 12 weeks of anti-TNF-α or other treatments in association with proton-pump inhibitors. RESULTS Upper CD involvement was found in 19/119 (16%) patients. Hp infection was detected in 10/119 (8.4%) CD patients. Hp-negative focally active chronic gastritis was found in 34/119 (28.6%) CD patients. At presentation, 12/19 patients (63%) showing upper CD involvement were asymptomatic and 7 (37%) symptomatic. CONCLUSION A high prevalence of upper GI tract involvement has been observed in CD patients, irrespective of upper symptoms. This finding suggests the usefulness of routine upper endoscopy in the diagnostic work-up of CD patients in order to correctly classify the distribution and extent of the disease.
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Wang Y, Bennett AE, Cai H, Lian L, Shen B. Evaluation of upper and lower gastrointestinal histology in patients with ileal pouches. J Gastrointest Surg 2012; 16:572-80. [PMID: 22052108 DOI: 10.1007/s11605-011-1766-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2011] [Accepted: 10/19/2011] [Indexed: 01/31/2023]
Abstract
BACKGROUND Inflammatory complications of ileal pouch-anal anastomosis (IPAA), including pouchitis and Crohn's disease (CD) of the pouch, are common in patients with restorative proctocolectomy for ulcerative colitis. It is not clear whether these inflammatory conditions can affect upper GI tract. The aim of the study was to evaluate correlation between duodenal and pouch histology in patients with healthy and diseased pouches. METHODS All IPAA patients who had esophagogastroduodenoscopy with biopsy after colectomy (N = 96) were included. H&E slides of gastric, duodenal, neo-terminal ileum, and pouch body biopsies were blindly re-reviewed by an expert GI pathologist for acute and chronic inflammation. Demographic and clinical variables and pouch outcome were analyzed. RESULTS There was a significant correlation between acute inflammation in the duodenum as measured by neutrophil infiltration score and the presence of chronic pouchitis (kappa coefficient = 0.21, P < 0.05). Intraepithelial lymphocytosis of the duodenum, though uncommon, only occurred in patients with irritable pouch syndrome, chronic pouchitis, or CD of the pouch. Crypt distortion of duodenal epithelium was only seen in patients with inflammatory or structural diseases of the pouch, including acute (18.2%) and chronic (5%) pouchitis, CD of the pouch (14.3%), and surgical complications of the pouch (14.4%). CONCLUSION Histologic evaluation of duodenal biopsy may provide additional information in patients with ileal pouches, as patients with normal histology of the pouch may have an abnormal duodenal histology.
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Affiliation(s)
- Yinghong Wang
- Victor W. Fazio, MD Center for Inflammatory Bowel Disease, Digestive Disease Institute, Cleveland, OH 44195, USA
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Turner D, Griffiths AM. Esophageal, gastric, and duodenal manifestations of IBD and the role of upper endoscopy in IBD diagnosis. Curr Gastroenterol Rep 2009; 11:234-7. [PMID: 19463224 DOI: 10.1007/s11894-009-0036-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Upper gastrointestinal (GI) tract inflammation in inflammatory bowel disease has become increasingly recognized, even in the absence of specific localizing symptoms, as patients more frequently undergo upper endoscopy. Although the recent Montreal classification system allowed classification of upper GI involvement in Crohn's disease (CD), independent of other locations, a consensus regarding the definition of what qualifies as significant "involvement" is still lacking. Reported incidence data vary considerably depending on the definitions used and the selected target population. Pediatric data suggest that upper endoscopy is useful in differentiating CD from ulcerative colitis, when inflammation is otherwise predominantly confined to the colon; however, this question has yet to be studied in adults. Infliximab therapy for upper GI-CD seems as effective as that seen for more distal GI inflammation.
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Affiliation(s)
- Dan Turner
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Hospital for Sick Children, Toronto, Canada
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32
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Umehara Y, Kudo M, Kawasaki M. Crohn's disease with gastroduodenal mucosa lesions that are similar to the lesions caused by ulcerative colitis. Inflamm Bowel Dis 2009; 15:646-8. [PMID: 18798564 DOI: 10.1002/ibd.20685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
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ROBERT MARIEE. Inflammatory Disorders of the Small Intestine. SURGICAL PATHOLOGY OF THE GI TRACT, LIVER, BILIARY TRACT, AND PANCREAS 2009:321-354. [DOI: 10.1016/b978-141604059-0.50016-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Garrido Gómez E, Lopez San Román A, Bermejo San José F. Idiopathic pancreatitis in inflammatory bowel disease. J Crohns Colitis 2008; 2:237-40. [PMID: 21172217 DOI: 10.1016/j.crohns.2008.03.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2008] [Accepted: 03/18/2008] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The incidence of pancreatitis is increased in inflammatory bowel disease. However, pancreatitis as an extraintestinal manifestation of the intestinal disease is exceedingly rare. We have retrospectively analyzed the prevalence of pancreatitis in a combined hospital cohort, and specifically studied cases in which no other cause than the intestinal disease itself could be found. METHODS The prevalence of pancreatitis in 1057 inflammatory bowel disease patients from two hospitals in the Community of Madrid, Spain, was determined by means of database examination. RESULTS The prevalence of pancreatitis was 2.74% (29 cases); only in four patients (0.38%) it was considered idiopathic and thus a possible extraintestinal manifestation. Underlying chronic pancreatitis was identified in three of these four patients. CONCLUSIONS In inflammatory bowel disease patients, pancreatitis is more often due to a nonrelated cause, and cases that can be adscribed to extraintestinal manifestation of the intestinal disease are comparatively rare.
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Affiliation(s)
- Elena Garrido Gómez
- Servicio de Gastroenterología, Hospital Universitario Ramón y Cajal, Madrid, Spain
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35
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Kuriyama M, Kato J, Morimoto N, Fujimoto T, Okada H, Yamamoto K. Specific gastroduodenoscopic findings in Crohn's disease: Comparison with findings in patients with ulcerative colitis and gastroesophageal reflux disease. Dig Liver Dis 2008; 40:468-75. [PMID: 18328794 DOI: 10.1016/j.dld.2008.01.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2007] [Revised: 01/16/2008] [Accepted: 01/21/2008] [Indexed: 12/11/2022]
Abstract
BACKGROUND Crohn's disease patients often carry gastroduodenal lesions. However, few reports have addressed specific gastroduodenoscopic findings in Crohn's disease patients. METHODS The gastroduodenoscopic findings of 63 Crohn's disease patients were examined. Those of 62 ulcerative colitis and 63 age- and gender-matched gastroesophageal reflux disease patients were also reviewed as controls. Findings of bamboo-joint-like appearance, gastric antral erosions, and duodenal lesions were the specific findings that were highlighted. RESULTS Of 63 Crohn's disease patients, 47 (75%) had at least one of the specific gastroduodenoscopic findings, and the prevalence of these findings was significantly higher in Crohn's disease patients than in ulcerative colitis and gastroesophageal reflux disease patients (ulcerative colitis, 24/62, 39%; gastroesophageal reflux disease, 15/63, 24%, P < 0.0001). In particular, bamboo-joint-like appearance was almost unique to Crohn's disease patients (Crohn's disease, 28/63, 44%; ulcerative colitis, 3/62, 5%; gastroesophageal reflux disease, 0/63, 0%, P < 0.0001). Analysis of the relationship between the Crohn's disease patient's background and gastrodunodenoscopic findings revealed that both patients with disease affecting the ileum and those with previous gut operations were more likely to exhibit the specific gastroduodenoscopic findings (P = 0.030 and P = 0.043, respectively). CONCLUSION Specific gastroduodenoscopic findings were observed in Crohn's disease patients. In particular, bamboo-joint-like appearance could be a unique marker of Crohn's disease.
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Affiliation(s)
- M Kuriyama
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1, Shikata-cho, Okayama 700-8558, Japan
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Esophageal, gastric, and duodenal manifestations of IBD and the role of upper endoscopy in IBD diagnosis. Curr Gastroenterol Rep 2008; 9:475-8. [PMID: 18377798 DOI: 10.1007/s11894-007-0062-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Upper gastrointestinal (GI) tract inflammation in inflammatory bowel disease has become increasingly recognized, even in the absence of specific localizing symptoms, as patients more frequently undergo upper endoscopy. Although the recent Montreal classification system allowed classification of upper GI involvement in Crohn's disease (CD), independent of other locations, a consensus regarding the definition of what qualifies as significant "involvement" is still lacking. Reported incidence data vary considerably depending on the definitions used and the selected target population. Pediatric data suggest that upper endoscopy is useful in differentiating CD from ulcerative colitis, when inflammation is otherwise predominantly confined to the colon; however, this question has yet to be studied in adults. Infliximab therapy for upper GI-CD seems as effective as that seen for more distal GI inflammation.
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37
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Abstract
The discovery of Helicobacter pylori and its intimate role in the development of the most common form of chronic gastritis has elicited a much-needed interest in non-neoplastic gastric pathology. This has been paralleled by an increase in upper endoscopic examinations, which allow recognition of novel patterns and distribution of mucosal injury. Numerous attempts at classification have been made, most based on the acuteness or chronicity of gastric mucosal injury. In this review, we will not offer a new classification but present a detailed description of the major clinicopathological entities, based either on the salient morphological features or the underlying aetiologies, i.e. iatrogenic, autoimmune, vascular or idiopathic.
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Affiliation(s)
- A Srivastava
- Department of Pathology, Dartmouth Hitchcock Medical Center and Dartmouth Medical School, Lebanon, NH, USA
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Knapp AB, Mirsky FJ, Dillon EH, Korelitz BI. Successful infliximab therapy for a duodenal stricture caused by Crohn's disease. Inflamm Bowel Dis 2005; 11:1123-5. [PMID: 16306777 DOI: 10.1097/01.mib.0000191612.43584.94] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Affiliation(s)
- Costas H Kefalas
- Division of Gastroenterology, Department of Internal Medicine, Baylor University Medical Center, Dallas, Texas 75246, USA.
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40
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Moriyama T, Matsumoto T, Jo Y, Yada S, Hirahashi M, Yao T, Iida M. Mucosal proinflammatory cytokine and chemokine expression of gastroduodenal lesions in Crohn's disease. Aliment Pharmacol Ther 2005; 21 Suppl 2:85-91. [PMID: 15943853 DOI: 10.1111/j.1365-2036.2005.02480.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The stomach and the duodenum are frequent sites of involvement by diminutive lesions in Crohn's disease (CD). AIM To assess mucosal proinflammatory cytokines and chemokines in gastroduodenal lesions of CD. METHODS 13C-Urea breath test and upper endoscopy were performed in 29 CD patients and seven control subjects, and biopsy specimens were obtained from the gastric cardia and the duodenum. Histology and mucosal levels of IL-1beta, IL-8/CXCL8 and RANTES/CCL5 were assessed and compared according to the presence of gastric cardial lesion [bamboo joint-like appearance (BJA)] and duodenal lesion (notched appearance, aphthous erosion and polypoid lesion). In 11 CD patients, these procedures were repeatedly performed after administration of famotidine. RESULTS H. pylori was less frequently positive in CD patients than in controls (10% vs. 71%, P = 0.003). Prevalence of cardial and duodenal lesion was significantly higher in CD than in controls (59% vs. 0%, P = 0.008 for gastric lesion; 45% vs. 0%, P = 0.034 for duodenal lesion). There were no differences in IL-1beta, IL-8 and RANTES between CD and controls. Duodenal mucosal IL-1beta and IL-8 were significantly higher in positive duodenal lesion than in negative duodenal lesion. However, there were no such differences with respect to cardial lesions. Endoscopic findings remained unchanged after administration of famotidine, while there was a trend towards decreases in IL-1beta and IL-8 in the gastric cardia. CONCLUSIONS The pathogenesis of diminutive lesions of CD may be different between the stomach and the duodenum. Famotidine may not have a therapeutic effect on duodenal lesion in CD.
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Affiliation(s)
- T Moriyama
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Maidashi, Fukuoka, Japan.
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41
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Yung K, Oviedo J, Farraye FA, Becker JM, Andrews CW, Lichtenstein D. Ampullary stenosis with biliary obstruction in duodenal Crohn's disease: a case report and review of the literature. Dig Dis Sci 2005; 50:1118-21. [PMID: 15986865 DOI: 10.1007/s10620-005-2715-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Kenny Yung
- Section of Gastroenterology, Boston University Medical Center, Boston, Massachusetts 02118, USA
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42
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Maeda K, Okada M, Seo M, Aoyagi K, Yamaguchi M, Sakisaka S. Evaluation of gastroduodenal mucosal lesions in patients with Crohn's disease and ulcerative colitis. Dig Endosc 2004. [DOI: 10.1111/j.1443-1661.2004.00343.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
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Abstract
Emergency complications of IBD are rare, but may be life-threatening, require surgery, and result in permanent end organ damage. The most common complications associated with UC are fulminant colitis, toxic megacolon, and bleeding. Each of these complications may resolve with aggressive medical therapy but often result in a total proctocolectomy. The most common complications associated with CD are abscesses and intestinal obstruction. Although initial treatment includes medical treatment, these Crohn's-related complications usually require a surgical intervention and intestinal resection. Finally, the most common extraintestinal manifestations that present as an emergency include thromboembolic events, ocular complications, and hepatobiliary disease. Some of these complications may parallel the course of the underlying disease and respond to IBD treatment, but thromboemboli, uveitis, and PSC do not. In the last decade there has been an explosion of knowledge and discovery into the pathogenesis of IBD. These findings have led to better and earlier treatment of IBD that it is hoped will alter the natural course of disease and prevent many of the complications outlined in this article.
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Affiliation(s)
- Onki Cheung
- Inflammatory Bowel Disease Center, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Scaife Hall, Room 566, 3550 Terrace Street, Pittsburgh, PA 15261, USA
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Abdullah BA, Gupta SK, Croffie JM, Pfefferkorn MD, Molleston JP, Corkins MR, Fitzgerald JF. The role of esophagogastroduodenoscopy in the initial evaluation of childhood inflammatory bowel disease: a 7-year study. J Pediatr Gastroenterol Nutr 2002; 35:636-40. [PMID: 12454578 DOI: 10.1097/00005176-200211000-00009] [Citation(s) in RCA: 119] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To assess the role of esophagogastroduodenoscopy in the evaluation of children with suspected inflammatory bowel disease. METHODS All children with inflammatory bowel disease who underwent esophagogastroduodenoscopy during their initial evaluation at our institution during a 7-year period (December 1993 to November 2000) were included in the study. RESULTS The study included 115 patients: 81 with Crohn disease (mean age, 11.34 years; 42 males) and 34 with ulcerative colitis (mean age, 11.79 years; 20 males). Abnormal findings on esophagogastroduodenoscopy were noted in 64% of patients with Crohn disease and 50% of children with ulcerative colitis; histologic abnormalities were found in 81.6% and 70.6% of the patients, respectively. Granulomas were found in the upper gastrointestinal tracts of 23 of 81 patients (28.4%), with the most common site being the gastric mucosa. Nine of these 23 patients had granulomas solely in the upper gastrointestinal tract. Additional unsuspected pathology noted included: candidiasis, hiatal hernia, Helicobacter pylori infection, and giardiasis. CONCLUSIONS Endoscopic and histologic abnormalities were found in the upper gastrointestinal tracts of a significant number of children with inflammatory bowel disease. While the mechanism(s) underlying these abnormalities in patients with ulcerative colitis is unclear, the pathology can contribute to the patient's clinical condition. Pathology in the upper gastrointestinal tract should not exclude a diagnosis of ulcerative colitis. Granulomas, confirming the diagnosis of Crohn disease, were found in the upper gastrointestinal tracts of 28% of our patients with Crohn disease. In some cases, granulomas were found solely in the upper gastrointestinal tracts. Based on our data, esophagogastroduodenoscopy with biopsy should be performed in all pediatric patients with suspected inflammatory bowel disease.
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Affiliation(s)
- Bisher A Abdullah
- Division of Gastroenterology, James Whitcomb Riley Hospital for Children, Indiana University Medical Center, Indianapolis, USA
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Abstract
UNLABELLED Crohn's disease may exceptionally be revealed by recurrent pancreatitis. CASE REPORT A 12-year-old boy presented with recurrent pancreatitis without recognized etiology. At the fourth episode, abdominal pain and abscess of the anus led to the diagnostic of Crohn's disease. Corticotherapy was successful on pancreatic and intestinal manifestations. CONCLUSION Recurrent pancreatitis may reveal Crohn's disease. Endoscopic examination of the duodenum and the colon is recommended in patients with recurrent pancreatitis and negative etiologic investigations.
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Affiliation(s)
- G Barba
- Unité de gastroentérologie pédiatrique, hôpital des Enfants, place Amélie-Raba-Léon, 33076 Bordeaux, France
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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; 7:328-37. [PMID: 11720325 DOI: 10.1097/00054725-200111000-00010] [Citation(s) in RCA: 68] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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.
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Affiliation(s)
- R A van Hogezand
- Department of Gastroenterology-Hepatology, Leiden University Medical Center, The Netherlands.
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Miehsler W, Püspök 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; 7:99-105. [PMID: 11383598 DOI: 10.1097/00054725-200105000-00004] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND To follow-up clinical and biochemical features in patients with Crohn's disease (CD) of the upper gastrointestinal (GI) tract and to evaluate the impact of different therapeutics on the outcome of these patients. METHODS 32 CD patients with endoscopically and histologically proven CD of the upper GI tract were included into this retrospective study. Gastroduodenal and intestinal permeability tests, inflammatory parameters, Crohn's Disease Activity Index (CDAI), and upper gastrointestinal complaint profile were sequentially assessed. These parameters were assessed at the beginning and followed up during therapies with antisecretory drugs, mesalamine, prednisolone, and azathioprine. RESULTS Symptoms responded to antisecretory drugs. Gastroduodenal permeability increased under mesalamine. Gastroduodenal and intestinal permeability as well as CDAI decreased under prednisolone. Under azathioprine, gastroduodenal and intestinal permeability, CDAI, and C-reactive protein decreased.
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Affiliation(s)
- W Miehsler
- Department of Internal Medicine IV, University of Vienna, Austria.
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Wagtmans MJ, Verspaget HW, Lamers CB, van Hogezand RA. Gender-related differences in the clinical course of Crohn's disease. Am J Gastroenterol 2001; 96:1541-6. [PMID: 11374696 DOI: 10.1111/j.1572-0241.2001.03755.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The aim of this study was to analyze the clinical and epidemiological differences between women and men affected by Crohn's disease. METHODS The clinical course of 275 female Crohn's disease patients was compared with that of 266 male patients. RESULTS Mean age at onset of symptoms and at diagnosis was 25.7 yr versus 27.7 yr and 28.8 yr versus 30.7 yr in women and men, respectively. Mean lag-time between onset of symptoms and establishment of the diagnosis were similar in both groups, without differences in presenting symptoms and initial localization of lesions. In women, however, some extraintestinal manifestations of Crohn's disease were found to occur more often. The percentage of patients who underwent an abdominal operation was quite similar in both groups (81% vs 77%). Mean lag-time between onset of symptoms and first bowel resection was not different. However, the lag-time between bowel resection and recurrence of disease was significantly shorter in women than in men (respectively, 4.8 yr vs 6.5 yr, p = 0.04), particularly regarding primary ileocecal resections. Overall, ileocecal resections were significantly more frequently performed in female than male patients (44% and 32%, respectively, p = 0.004). Female patients were also found to have significantly more often relatives in the first or second degree affected by Crohn's disease than male patients (15% vs 8.3%, p = 0.02). CONCLUSIONS Extraintestinal manifestations occur more often in female Crohn's disease patients than in male patients. Furthermore, an ileocecal resection, which is accompanied by an earlier recurrence, is more often performed in female than in male patients. Female patients have more often relatives with the same disease.
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Affiliation(s)
- M J Wagtmans
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, The Netherlands
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Korelitz BI, Rajapakse R. Ulcerative duodenitis with ulcerative colitis: is it Crohn's disease or really ulcerative colitis? J Clin Gastroenterol 2001; 32:97. [PMID: 11205662 DOI: 10.1097/00004836-200102000-00001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
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Abstract
Historically, Crohn's disease of the esophagus, stomach, and duodenum has been reported only rarely. With more frequent use of upper endoscopy, however, upper gastrointestinal involvement has been found to be more common than previously suspected. The surgeon with an interest in Crohn's disease needs to be familiar with all areas that are potentially affected in this perplexing and sometimes devastating disease. This article examines the literature on foregut Crohn's and discusses the incidence, clinical manifestations, diagnosis, medical management, surgical indications, and operative techniques.
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Affiliation(s)
- H L Reynolds
- Department of Surgery, University Hospitals of Cleveland, Ohio, USA
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