Balloon dilation with corticosteroid injections a durable endoscopic option for Crohnʼs-related pyloric stenosis

Abstract

Pyloric stenosis due to Crohn's disease is relatively rare. There is no consensus regarding the management of this complication. Fibrostenotic lesions in Crohn's disease are typically resistant to pharmacologic therapy. Patients with gastroduodenal Crohn's disease often require surgical intervention. Balloon dilation with or without corticosteroid injections have been found to be effective in the management of stenosis in the distal small bowel and colon. We report a case which illustrates that intralesional corticosteroid injection and balloon dilation of Crohn's-related pyloric stenosis is an effective and durable intervention. A 25 year old Caucasian woman presented with a 1 year history of progressive nausea, vomiting, bloating, abdominal pain and intermittent diarrhea. An upper endoscopy showed pyloric stenosis with biopsies revealing chronic active inflammation and non-caseating granulomas. There was no evidence of Helicobacter pylori. A subsequent colonoscopy revealed scattered areas of erythema interspersed with normal mucosa in the terminal ileum and colon. Biopsies revealed chronic active inflammation with non-caseating granulomas. She was treated with mesalamine and 6-mercaptopurine with improvement of her abdominal discomfort and resolution of her diarrhea. However, she had persistent nausea, vomiting, abdominal distension and unintentional weight loss. Controlled Radial Expansion (CRE) balloon dilation to 8 mm was performed of her pyloric stenosis with some improvement of her symptoms. During the subsequent 18 month period, she underwent 5 endoscopies with triamcinalone injection and CRE balloon dilatation (to maximum of 15 mm) of the pylorus with progressive improvement and ultimate resolution of her symptoms. She has been maintained on mesalamine and 6-mercaptopurine for 10 years with no recurrence of her obstructive symptoms. Crohn's disease is frequently complicated by fibrostenosis. Pharmacologic management often is attempted, however ∽30% of patients will require surgical intervention. Post-operative course is often complicated by recurrence. Avoidance of surgical intervention is desired if possible. Endoscopic management of fibrostenosis may alleviate the need for surgical intervention in selected patients. This case demonstrates a durable endoscopic approach to the management of pyloric stenosis due to Crohn's disease.