Intest Res.  2021 Oct;19(4):472-477. 10.5217/ir.2020.00072.

Pediatric Crohn’s disease with severe morbidity manifested by gastric outlet obstruction: two cases report and review of the literature

• Kim ES
• Park JH
• Choe YH
• Kim MJ

• KMID: 2521611
• DOI: http://doi.org/10.5217/ir.2020.00072

Abstract

Crohn’s disease (CD) presenting as gastric outlet obstruction is rare but serious clinical presentation of CD causing severe morbidity. However, there have been few case reports concerning this disorder in East Asian children and adolescents. The current case report describes 2 pediatric patients with CD who had had gastric outlet obstruction as an initial symptom of CD. Two pediatric patients developed postprandial vomiting, bloating, and unintentional weight loss. The upper endoscopy result indicated that there was pyloric obstruction with mucosal edema, inflammation and ulcers. The serologic test and colonoscopy results suggested CD. These patients were treated with infliximab, and endoscopic balloon dilation without surgery and showed remarkable improvement in obstructing symptoms with maintaining clinical and biochemical remission. This case report elucidates the benefits of early intervention using infliximab and endoscopic balloon dilation to improve gastric outlet obstruction and achieve baseline recovery in patients with upper gastrointestinal B2 phenotype of CD.

Keyword

Gastric outlet obstruction; Crohn disease; Pediatric

Figure

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  Fig. 1. Esophagogastroduodenoscopy at diagnosis (case 1). (A, B) Upper endoscopic findings at referral. Reflux esophagitis at low esophagus, multiple esophageal ulcers, and significant narrowing of pylorus. (C, D) Follow-up upper endoscopic findings after 11 weeks. Apparent pyloric obstruction and multiple ulcerations on antrum. (E, F) Fluoroscopically guided balloon dilation. (G, H) Follow-up upper endoscopic findings after 20 weeks. Remarkable improvement of reflux esophagitis and pyloric obstruction.

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  Fig. 2. Colonoscopy at referral (case 1). (A) Multiple erosions in terminal ileum. (B) Mild swelling in ileocecal valve.

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  Fig. 3. Histopathologic findings of cases. (A) Case 1: gastric biopsy specimens showing small clusters of lymphocytes in the lamina propria, also called as focally enhanced gastritis (H&E, ×4). (B) Case 1: terminal ileal biopsy specimens showing villous blunting, crypt distortion and increased lymphoplasmacytic infiltration (H&E, ×4). (C) Case 2: colonic biopsy specimens showing a shallow ulcerative lesion and increased lymphoplasmacytic infiltration in submucosal layer and lamina propria of mucosa (H&E, ×4).

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  Fig. 4. Abdomen imaging at referral (case 1). (A) Plain X-ray revealed severe distended stomach (arrow) due to obstruction. (B) Magnetic resonance enterography revealed markedly distended stomach with gastric outlet obstruction, and limited evaluation of small bowel loops because of poor passage of contrast and collapse of small bowel.

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  Fig. 5. Esophagogastroduodenoscopy and colonoscopy at referral (case 2). (A) Upper endoscopic findings at referral. Edematous mucosa, multiple pyloric ulcers, and significant narrowing of pylorus. (B) Several multiple aphthous ulcers in terminal ileum, and cecum to sigmoid colon.

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