Esophageal Crohnʼs Disease, Depression, and Eating Disorder: A Clinical Conundrum

Abstract

Purpose: Involvement of the esophagus occurs in only 0.2% of Crohn's disease cases. Isolated Crohn's disease of the esophagus is exceedingly rare with only a handful of cases reported in the literature. This is a case of Crohn's disease with only esophageal involvement, but with the diagnosis made challenging in the setting of severe depression and possible eating disorder. Methods: A 29 year old female with a history of depression and possible eating disorder presented to a tertiary referral medical center for further evaluation of weight loss in the context of esophageal strictures. She had a long history of depression as well as previous diagnosis of nonspecific eating disorder with past hospitalization in an inpatient eating disorder unit. She initially presented with symptoms of dysphagia and 12 kg weight loss to an outside institution where upper endoscopy was notable for diffuse inflammation mucosal edema, multiple pseudopolyps, diffuse scarring, esophageal ulcer and strictures. Initial concerns included caustic ingestion but the patient and her spouse repeatedly denied any such history. Colonoscopy with terminal ileum exam was negative. Despite multiple endoscopic dilatations, she remained symptomatic and presented to our institution for further evaluation. Repeat upper endoscopy was notable for findings limited to the esophagus which included superficial ulcerations, multiple inflammatory pseudopolyps, and a stricture in the distal esophagus. Multiple biopsies were obtained and notable for findings of a non-necrotizing epithelioid granuloma and deep mucosal inflammation. Small bowel interrogation with MR Enterography was negative. Evaluation by Psychiatry was notable for findings consistent with depression but equivocal for an eating disorder. Initial therapy for Crohn's disease was started with oral budesonide gel. Following ten weeks of therapy, she remained symptomatic. Results: Although plans were made to escalate therapy, this was postponed as the patient was hospitalized in an inpatient psychiatric unit due to worsening depression. Conclusion: Crohn's disease with esophageal involvement is rare and exceedingly so when it is isolated to the esophagus. Psychiatric disorders are significant comorbidities and are common in the community. This is a case of Crohn's disease limited to the esophagus, in which the diagnosis and management were complicated by significant psychiatric comorbidities. This emphasizes the importance of clinical vigilance as well as impact of psychiatric comorbidities on medical care.