Double-Edged Sword: Esophageal and Colonic Crohn's Disease.

Abstract

A 50-year-old woman of northern European ancestry diagnosed with ulcerative colitis (UC) 15 years previous was admitted to the hospital due to a 2-week history of severe dysphagia, odynophagia, and cramping, diffuse abdominal pain associated with diarrhea. She described painful swallowing, mostly to solids but occasionally to liquids, centered in the upper mid-chest that felt like ‘‘swallowing swords.’’ She limited her intake only to liquids and broth; for 2 days before admission, she was unable to tolerate anything by mouth, including her own saliva. In conjunction with her esophageal symptoms, she noted cramp-like, diffuse, moderately severe abdominal pain, worsening watery, non-bloody diarrhea occurring up to six times per day and at night, urgency, and ‘‘shearing’’ anal pain with defecation. She denied any fever or chills, but reported a 7-kg weight loss during the past month. Although her primary physician initiated treatment with ciprofloxacin and metronidazole for suspected worsening colitis and referred her to a gastroenterologist, given the intensity of her odynophagia, she visited the Emergency Department for further treatment. Her past medical history was significant for the diagnosis of UC that had been until recently maintained in remission with the use of oral mesalamine, 1.2 g per day. She also had a history of heartburn, treated with pantoprazole, and seizure disorder that had been inactive without therapy for several years. Her last colonoscopy performed 6 years prior to this episode was interpreted as showing mild UC. Upon admission to the hospital, she was afebrile, tachycardic to 112 per min, with normal blood pressure and respirations. Examination was significant only for diffuse abdominal tenderness, hyperactive bowel sounds, and brown occult blood-positive stool. She had no oral or perianal abnormalities. Admission laboratory examination included WBC = 10.8, Hgb = 11.6, and platelets = 502; a comprehensive chemistry panel was normal. Urinalysis was notable for bacteriuria and pyuria, suggestive of a urinary tract infection. Tests for tuberculosis and human immunodeficiency virus (HIV) infection were negative. A chest X-ray was normal. A computed tomography (CT) scan of the abdomen and pelvis revealed colonic wall thickening, mostly in the splenic flexure and sigmoid colon, associated with numerous, mildly enlarged mesenteric and peri-aortic lymph nodes and multiple small liver cysts (Fig. 1). An urgent upper endoscopy showed a deep, linear, 3-cm-long non-bleeding ulcer in the proximal esophagus (Fig. 2); the remaining upper endoscopic examination was normal. Colonoscopy including terminal ileoscopy revealed a normal terminal ileum but extensive inflammation, nodularity, ulcerations, and friability of the colon, starting at the level of the rectosigmoid and extending in a scattered fashion to the hepatic flexure, with the most severe inflammatory changes in the distal transverse and descending colon (Fig. 3). Histologic examination of the biopsies revealed ulcerative esophagitis (Fig. 4) and severe colitis without dysplasia starting at the hepatic flexure and extending distally with microgranulomas at the splenic flexure (Fig. 4). The terminal ileum and cecum were histologically normal. Stool cultures were negative for bacterial, & George Triadafilopoulos vagt@stanford.edu