Isolated Gastroduodenal Crohnʼs Disease: Masked as a Malignancy

Abstract

Crohn's disease is a chronic idiopathic inflammatory disease of the GI tract which is usually associated with ileo-colonic and colonic/rectal involvement. The stomach and duodenum are rarely the sole predominant site of Crohn's disease. We report such a case where gastroduodenal Crohn's was interpreted as a malignancy. A 26 year-old male was referred to our clinic for a second opinion by an oncologist following an abnormal abdominal CT scan showing an antral mass suggestive of a malignancy, and an endoscopy with biopsy which showed atypical cells. He complained of intermittent epigastric pain and post-prandial nausea and vomiting for over 9 years. His symptoms had failed to respond to proton pump inhibitors and diet modification. He also reported unintentional weight loss of over 60 lbs within a period of 6-7 years. He denied smoking or alcohol abuse. He had no other medical conditions, and he denied any family history of intestinal tract malignancy or bowel disease. He was cachectic and in mild distress from epigastric discomfort. He was hemodynamically stable. Abdominal examination revealed mild epigastric tenderness on deep palpation. There were no oral ulcers, lymphadenopathy, or anal fissures or fistulas. The remainder of his physical examination was normal. He had a microcytic anemia and a normal complete metabolic profile. Tests for TB and HIV were negative. Chest x-ray was normal. Colonoscopy with terminal ileoscopy was unremarkable. An endoscopic ultrasound revealed diffuse thickening of the antral wall with no other abnormality. An upper endoscopy showed markedly abnormal granular, edematous, friable, and ulcerated mucosa involving the antrum, pre-pyloric region, and the pylorus, with mild gastric outlet obstruction. The duodenal bulb and second portion were also involved. There was extensive superficial ulceration and overlying exudate. Biopsy showed chronic inflammation with granulation tissue and multinucleated giant cell formation. Stain for H. pylori was negative. He was started on a proton pump inhibitor, sucralfate, and prednisone with marked resolution of symptoms. This case demonstrates a rare presentation of isolated gastroduodenal Crohn's disease mimicking a gastric malignancy. Gastroduodenal Crohn's can easily be confused with other diseases, including peptic ulcer disease and, as in our patient, malignancy. The characteristic findings on endoscopy and adequate biopsies usually aid the diagnosis. Close follow up is suggested as up to one third of these patients develop distal disease over time. Although management remains controversial, initiation of steroids and proton pump inhibitors have been shown to be helpful symptomatically.