A Mimicker of Crohnʼs Disease

Abstract

Purpose: Linitis plastica is the diffuse type of gastric adenocarcinoma in which the individual cells infiltrate the gastric wall without forming a discrete mass. It typically presents in younger patients and portends a poorer prognosis than the intestinal type of gastric adenocarcinoma. We present a case of metastatic linitis plastica, which was initially misdiagnosed as Crohn's disease. Methods: Case report Results: A 55 year old male presents with pain on defecation, tenesmus, intermittent hematochezia and epigastric abdominal pain. His symptoms began 7 months prior to presentation, during which time he lost 30 lbs. The patient underwent an upper endoscopy and colonoscopy, demonstrating gastric mucosal erythema as well as a stricture and area of erythema in the distal sigmoid. Biopsies of the gastric and colonic mucosa demonstrated “inflammatory changes”. The patient was diagnosed with Crohn's disease and started on a course of steroids and mesalamine. Despite two months on this regimen, the patient's condition did not improve and the patient was referred to a tertiary care center. A repeat endoscopy demonstrated a poorly distensible stomach (Fig. A) and a loss of rugal folds in the body of the stomach (Fig. B). Colonoscopy again demonstrated a stricture in the sigmoid colon. Biopsies from both the stomach and sigmoid colon demonstrated a diffuse, poorly differentiated carcinoma with signet ring cells. A CT scan of the abdomen and pelvis demonstrated diffuse wall thickening of the stomach (Fig. C) and the rectum. The patient was diagnosed with linitis plastica with metastases to the colon. The patient decided to pursue hospice care. Conclusion: In the setting of mucosal inflammation, endoscopic forcep biopsies may not reveal an underlying layer of malignant tissue, which can lead to a delay in diagnosis as in the case presented. However, the combination of a poorly distensible stomach, a diffuse loss of rugal folds in the body of the stomach and a history of weight loss should raise suspicions of malignancy, and specifically linitis plastica. Although a relatively uncommon malignancy, a high index of suspicion and recognition of the characteristics of this malignancy aid earlier diagnosis.Figure