Duodenal Crohn’s disease: Case report and systematic review

Table 1 Information from the studies reviewed

Ref.	Study population	Study design	Presentation/investigation	Result	Treatment
Song et al[38], 2016	A single case	Observational study (case report)	Presentation: Constant epigastric soreness with a month of dyspepsia. Investigations: EGD, colonoscopy, physical examination, biopsy, histology, chest X-ray, blood works and vital signs checks	Vital signs were normal. Physical examination showed no epigastric tenderness. Chest X-ray was unremarkable. Blood works showed no alarming result. Colonoscopy showed unremarkable terminal ileum and entire colon. EGD showed multiple progressive ulcers and erosion in the duodenal bulb and second portion of the duodenum with mucosal oedematous. Biopsy and histology showed ulceration of the duodenal bulb indicating erosion of the infiltration of inflammatory cell	20 mg of prednisolone was given for two week and reduced to 10 mg for 1 wk and reduced to 5 mg after a week to take for a week
Lightner et al[68], 2018	A single patient	Observational study (case report)	Presentation: Early satiety, distention, recent weight loss, nausea, microcytic anaemia, and vomiting. Investigations are: MRE, biopsy, EGD and histology	MRE showed high grade stricture in the distal portion of the abnormal segment resulting in dilatation of both the stomach and the second part of the duodenum. EGD showed ulceration with stenosis in D2 and stricture in D3 and oedema in the surrounding the area which confirmed the finding of MRE to be highly suspicious of duodenal Crohn’s disease. Histology confirmed the suspicion of EGD	Laparoscopic gastroduodenal bypass with ongoing proton pump inhibitor
Ashraf et al[56], 2022	A single case	Observational study (case reports)	Presentation: 6 mo of 60 pounds weight loss, intractable nausea, mild epigastric pain, and vomiting. Investigations: CT, biopsies and EGD	CT result showed distention of the stomach with tapering into the proximal duodenum followed by a marked diffuse distention of the rest of the duodenum and narrowing of the duodenojejunal junction. Biopsy showed duodenitis consistence with duodenal Crohn’s disease. EGD showed stricture at proximal of the duodenum, distended duodenum, and stricture at the duodenojejunal junction coupled with severe stenosis and inflamed mucosa	PEG J tube was inserted for feeding but the patient did not tolerate. A duodenal resection was done
Plerhoples et al[37], 2012	A single case	Observation (case reports)	Presentation: 25 yr of intermittent nausea, precipitous with loss of 50 pound in last 7 mo, bloating and vomiting. Investigations: EGD, colonoscopy, biopsy, fluoroscopy, and exploratory laparotomy	EGD showed ulcerating inflammation at the distal duodenum associated with stricture, dilation in the oesophagus and pyloric lumina and retained food in the proximal megaduodenum and antrum. Biopsy showed active acute inflammation. Fluoroscopy showed mild inflammation and delayed proximal duodenal and gastric emptying	Exploratory laparotomy with mobilization and duodenal bypass using antecolic roux-en-Y duodeno-jejunostomy bypas
Helms et al[55], 2016	A single case	Observational study (case report)	Presentation: Unintentional weight loss, abdominal pain, bright red blood in stool, vomiting and diarrhoea. Investigations: CT, colonoscopy, biopsy, EGD, and upper endoscopy	EDG showed persistence duodenal Crohn’s. Unremarkable CT. Colonoscopy showed ileocecal valve stenosis preventing intubation. Upper endoscopy showed partially gastric outlet obstruction, duodenitis couple with edematous stenosis. Biopsy showed duodinitis with granulating tissue and ulceration	Protonix, Amoxil and Biaxin were used to treat H. pylori. Asacol was used to treat Crohn’s flare up
Ehwarieme et al[39], 2015	A single case	Observational study (case report)	Presentation: Intermittent epigastric pain, post prandial nausea and vomiting for more than 9 yr and unintentional weight loss. Investigation: Chest X-ray, colonoscopy, endoscopic ultrasound, abdominal examination, biopsy, CT and upper endoscopy	CT showed antral mass which suggest malignancy. Initial endoscopy showed atypical cell. Chest X-ray is normal. Colonoscopy is unremarkable. Endoscopic ultrasound. Showed diffused thickening of the antral wall. Upper endoscopy showed oedematous, abnormal granular, ulcerated mucosa, friable affecting the duodenal bulb, pylorus, second part of the duodenum, antrum, pre pyloric area accompanied by a mild gastric outlet obstruction. Biopsy showed multinucleated cell and granulating tissue in addition to chronic inflammation	Patient was treated with proton pump inhibitor, prednisolone and sucralfate
Odashima et al[41], 2006	A single case	Observational study (case report)	Presentation: Abdominal pain, abdominal distention, vomiting and nausea. Investigation: CT, upper GI X-ray, endoscopy and biopsy	CT showed thickness of the duodenum wall. Upper GI X-ray showed duodenal stricture. Endoscopy revealed mucosal oedema, large ulceration and stricture in the duodenal bulb	Patient was treated with inflixamab
Nugent et al[14], 1977	36 patients	Retrospective study (case report)	Presentation: Abdominal pain, abdominal distention, vomiting and nausea significant weight loss. Investigation: Endoscopy, pathology features, radilogy features and abdominal examination	Endoscopy features showed superficial ulceration in duodenum and antrum with granular appearance in addition to stenosis. Radiology feature showed irregular thickness, oedema and cobblestone pattern of the mucosa. Pathology findings showed mesentric lymph node enlargement with oedema and thickness. Duodenal wall fibrosis with chronic inflammation was noted	Vagotomy, gastroenterostomy amd Billroth
Karateke et al[54], 2013	A single case	Observational study (case report)	Presentation: 6 mo of abdominal pain with progressive nausea, weight loss and bilious emesis. Investigation: Physical examination, CT routine blood work, biopsy, EGD and colonoscopy	Blood works showed mild normocytic anaemia. CT and colonoscopy are normal. Physical examination shows fulness and slight tenderness in the epigastric region. EGD showed tight stricture and oedema in the mucosal, long ulceration of the duodenal bulb and nearly complete obstruction. Biopsy showed cryptitis and severe inflammation, mixed chronic inflammatory infiltration of the laminal propria evidencing duodenal Crohn’s disease	Gastrojejunostomy without vagotmoy and subsequent proton pump inhibitor

CT: Computer tomography; EGD: Esophagogastroduodenoscopy; GI: Gastrointestinal; MRE: Magnetic resonance enterography.

Table 2 X-rays used by the studies in the review and their results

Type of X-ray	Number of studies	Results
Chest X-ray	2	Unremarkable
Upper GI X-ray	2	Duodenal stricture
Upper GI fluoroscopy	1	Delayed emptying in both proximal duodenal and gastric

GI: Gastrointestinal.

Table 3 Computed tomography features reported in the review

Features	Number of studies
Distention of stomach and duodenum including narrowing of the duodenojejunal junction	1
Antral mass	1
Wall thickness	1
Nothing unusual found	2

Table 4 Histology results from the biopsies

Duodenal biopsy and histology	Number of cases
Chronic inflammation	18
Erosion	1
Infiltration of inflammatory cells.	1
Granulomas	4
Foveolar metaplasia	2
Duodenitis	12
Increased intraepithelial lymphocytes	1
Fibrosis	17
Villous blunting	1
Ulceration	2
Acute active inflammation	2
Polynuclear cells	1

Table 5 Symptoms of Crohn’s disease in the studies reviewed

Symptoms	Cases
Epigastric pain	7
Weight loss	7
Nausea and vomiting	6
Vomiting	1
Dyspepsia	1
Abdominal distention	3
Upper GI bleeding	2
Microcytic anaemia	1
Diarrhoea	1

GI: Gastrointestinal.