Crohn's disease of the esophagus: dilation of stricture and fibrin sealing of fistulas

Crohn's Disease of the Esophagus, Duodenum, and Stomach

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.

Dysphagia in Crohn's disease: a diagnostic challenge

Dysphagia is a rare manifestation in a patient with Crohn's disease. We report on the case of a patient with long-standing Crohn's disease who developed progressive dysphagia over 3 years. Endoscopy showed minimal distal oesophagitis with non-specific histological findings. Further investigation with cinematography, barium swallow and manometry established an achalasia-like motility disorder. Biopsies obtained from the oesophagus were non-specific. Balloon dilatation was performed. Initial success was followed by recurrent dysphagia. At repeat endoscopy, an oesophageal fistula was detected. An attempt at conservative medical management failed and oesophagectomy was successfully performed. Pathology results of the resected specimen confirmed the suspected diagnosis of oesophageal Crohn's disease. Even if achalasia is suspected in a Crohn's patient, it should be taken into consideration that the motility disorder could be the result of a transmural inflammation with or without fibrosis caused by Crohn's disease.

Upper gastrointestinal tract endoscopy in inflammatory bowel disease

Upper gastrointestinal endoscopy is used to evaluate upper gastrointestinal symptoms in patients with inflammatory bowel disease. This article discusses the procedure, which may allow for the diagnosis of Crohn's disease of the esophagus, stomach, and/or duodenum. Biopsies of normal gastric mucosa in patients with indeterminate colitis may be helpful in making a diagnosis of Crohn's colitis. Upper gastrointestinal endoscopy may allow for therapeutic intervention in terms of bleeding and stricturing disease.

Crohn's disease of the foregut

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.

Esophagogastric fistula: a complication of Crohn's disease--case report and review of the literature

Esophagogastric fistula formation as a complication of esophageal Crohn's has been reported in only one case in the literature. In addition, only eight cases of esophageal fistulae of any type have been reported in the setting of Crohn's disease. Unlike the more often described superficial, aphthous disease of the esophagus, response of fistulae to medical therapy has been disappointing, and recurrence and progression are likely. Surgery remains the primary modality for refractory disease. The roles of salicylates, antibiotics, immunosuppressive agents, sealants, and intralesional steroid injections have not been well defined. We present a case of severe, refractory Crohn's disease with fistula formation between the esophagus and stomach, and concomitant involvement of the oropharynx, duodenum, terminal ileum, and cecum.

Surgical management and treatment of esophageal fistula

Esophageal fistula may involve the respiratory or cardiovascular system. Fistulas involving the respiratory system which originate from esophageal cancers are the most common. Diagnosis is best made with barium esophagogram. ERF of any cause usually leads to repetitive contamination of the respiratory tract, resulting in sepsis and death of the patient if untreated. In the case of MERF, whether from esophageal or lung cancer, only palliative treatment is usually possible. Better results, including cure, may be expected when a MERF is caused by lymphoma. Curative operation with closure of the fistula is usually possible for BERF if the fistula is identified and treated before irreversible damage has been done by infection, sepsis, and malnutrition. Esophagocardiovascular fistulas occur infrequently in comparison with ERF. These may involve the aorta, usually as a result of a thoracic aneurysm. Rarely one may encounter esophageal fistula to the pericardium or heart. Few survivors have been reported, but successful management is possible if early diagnosis is made and prompt surgical management is undertaken.