Gastroduodenal Crohn's Disease Research Articles

P044 A Profile of New Start IBD Patients on Multiple Advanced/Biologic Therapies.

After analyzing patient chart data from nearly 1,000 recently-initiated biologic/JAK inhibitor inflammatory bowel disease (IBD) patients, it was discovered that 6% are treated with multiple advanced/biologic therapies. This analysis sought to profile those new start patients on a multi-biologic/JAK inhibitor regimen against those treated with a single advanced therapy to determine the type of patient who is typically initiated on more than one advanced/biologic therapy, and why the combination is necessary. An independent market analytics firm collaborated with US gastroenterologists (n=197) to conduct a retrospective chart review of patients with inflammatory bowel disease (IBD) (n=999) who were started on a biologic agent for the first time. Gastroenterologists submitted patient-level data via a HIPAA-compliant audit form which included both clinical and non-clinical data. The data were collected and analyzed in April-June 2021. 7% of ulcerative colitis (UC) and 5% of Crohn's disease (CD) patients are currently treated with more than one biologic/JAK inhibitor. The most common therapy used in combination with another for UC is adalimumab (36%), followed by infliximab brand (18%), and ustekinumab (18%). For CD, the most common combinations involve infliximab brand (35%), followed by vedolizumab (22%), and ustekinumab (13%). The necessity for multiple biologic therapy is clarified when reviewing the IBD patients' comorbidities and medical history. The prevalence of ulcerative proctitis (34% vs. 11%) and gastroduodenal CD (43% vs. 4%) among multi-biologic/JAK inhibitor patients is higher than among those treated with one biologic/JAK inhibitor. Additionally, multi-biologic/JAK inhibitor patients have an increased prevalence of recent bowel perforation (16% vs. 1%) and surgical bowel re-section (10% vs. 3%) compared to those treated with just one advanced therapy. Due to this more severe disease profile, patients treated with more than one advanced/biologic therapy are more likely to report severe impairment in work performance (48% vs. 34%), chronic fatigue comorbidity (23% vs. 5%), more frequent ER visits per year (average= 2.3 vs. 1.1), and more frequent hospitalizations per year (2.0 vs. 0.6). A profile of new start biologic IBD patients ideal for concomitant advanced therapy emerged when reviewing almost 1,000 physician-reported patient records. These patients are more likely to have had gastroduodenal Crohn's disease and or recent bowel perforation or re-section. These patients are more likely to report impaired work performance, chronic fatigue, more frequent ER visits and more frequent hospitalizations.

Gastric Outlet Obstruction as a Manifestation of Recurrent Crohnʼs Disease

Introduction The most common complications of Crohn's disease are the development of fistulas[1], abscess formation, malabsorption of bile acids, and adhesions. Rarely, Crohn's disease involves the stomach and the duodenum. We present a case of gastric outlet obstruction due to recurrent Crohn's disease. Case Report A 55-year-old male with a history of Crohn's disease in remission since 1990 presented with two weeks of nausea, vomiting, and 20 lbs. of weight loss. He had a remote history of antrectomy and ileocecectomy with no available details. In 2011, he had pyloric and postbulbar stenosis that required endoscopic dilatation. A computed tomography of the chest, abdomen and pelvis with contrast showed no acute findings. An outpatient esophagogastroduodenoscopy showed gastric outlet obstruction due to anastomotic stenosis of a previous antrectomy site and he was admitted. Initially, we treated the patient conservatively with intravenous fluids and proton pump inhibitors. However, he continued to have severe symptoms and eventually underwent duodenectomy with gastroduodenostomy. There were massive adhesions secondary to prior surgeries. The pathology report of the pylorus and duodenum resection (Figures 1 and 2) showed suppurative and granulomatous inflammation with focal abscess formation, adhesions, and stenosis consistent with Crohn's disease. On the tenth day of hospitalization, the patient recovered and was discharged home. Discussion While no controlled studies have been reported for the management of gastroduodenal Crohn's disease, the initial treatment typically includes corticosteroids and aggressive suppression of gastric acid using a proton pump inhibitor. Endoscopic balloon dilation can be used in short strictures. More severe strictures may require bypass via a gastrojejunostomy or gastroduodenostomy[2].2085_A Figure 1. Surface ulceration, crypt architecture distortion, and acute inflammation in the lamina propria with focal cryptitis.2085_B Figure 2. Granulomatous formation.

Crohn Disease: A Case of Rare, Isolated Duodenal Involvement

Crohn disease is a chronic inflammatory condition that may present or recur in any region of the gastrointestinal (GI) tract. Gastroduodenal Crohn disease occurs in only 0.5% to 4% of all Crohn cases, with duodenal isolated disease accounting for less than 0.07% of all cases. The diagnosis of Crohn disease is based on clinical, laboratory, endoscopic, and histopathologic findings. Nugent and Roy criteria for gastroduodenal Crohn must include either 1. histologic finding of noncaseating granulomatous inflammation of the stomach or duodenum and absence of other systemic granulomatous disorders or 2. confirmed Crohn disease of the GI tract and radiographic or endoscopic findings of diffuse inflammation of the stomach or duodenum consistent with Crohn disease. A 37 year old male with history of GERD and Crohn disease presented to the ED for vomiting, abdominal pain, diarrhea, bright red blood in stool, and a 50-60 lb unintentional weight loss. PE was benign. CT abd/pel was unremarkable. Colonoscopy revealed stenosis of the ileocecal valve preventing intubation, likely from chronic inflammation. Upper endoscopy revealed first portion duodenitis with edematous stenosis and partial gastric outlet obstruction. Gastric biopsies resulted as active H. pylori gastritis. Duodenal biopsies showed duodenitis with ulceration and granulation tissue. The patient was treated with Protonix, Amoxil, and Biaxin for H. pylori and Asacol for the Crohn's flare. Follow-up EGD and biopsies showed persistent Crohn of the duodenum. Historically, Duodenal Crohn Disease (DCD) has been very difficult to treat. A large portion of the patient population fail medical therapy and require invasive intervention. Recent research has addressed the question of whether H. pylori plays a provocative vs protective role in IBD. In this case, an argument could be made that the H. pylori was the catalyst for the rare isolated case of DCD. According to Papamichael et al, H. pylori infection may invoke changes of gastric and intestinal permeability or immunological derangements from the absorption of bacterial particles. Reversely, the fact that the DCD did not respond to medical therapy after eradication of the H. pylori promotes the theory of H. pylori producing a protective environment. As evidenced by this case, further research involving the etiology and pathogenesis of rare, isolated DCD is critical to the management of the patient.

Isolated Gastroduodenal Crohnʼs Disease: Masked as a Malignancy

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.

Focally Enhanced Gastritis Used as a Histological Marker in Two Cases of Crohnʼs-like Disease

Purpose: Gastroduodenal involvement of Crohn's disease has not been well characterized and estimated to be about 4% in one UK series. Focally enhanced gastritis is common in Helicobacter pylori negative patients with known distal Crohn's disease regardless of presence of granulomas or mucosal lesions at endoscopy. Immunostaining from gastric biopsies may reveal distinctive pattern of accumulation of perifoveolar or periglandular inflammatory infiltrates (CD3/CD 68). This may alter treatment plans and improve outcome in patients with Crohn's-like disease with earlier medical intervention. Case 1: A 59-year-old woman with prior history of Hashimoto's thyroiditis presented with abdominal pain, iron deficiency anemia, vomiting and diarrhea for 1 year. Upper endoscopy showed antral ulcers; Helicobacter pylori and fasting gastrin were negative. She was treated with pantoprazole for presumed peptic ulcer disease. Still, she remained symptomatic. Focal perifoveolar infiltrates were seen on antral biopsies. IBD serology (Prometheus) was negative. Capsule endoscopy showed multiple aphthoid ulcers in long segments without stenosis (Lewis score 900). Erosions seen in transverse colon on colonoscopy in the absence of use of NSAIDs. There was no evidence of inflammatory on CT abdomen. CRP was 11.5. CDAI 283. She responded well to infliximab and achieved clinical remission (CDAI <150) with normalization of CRP. Endoscopy after induction showed reduction of ulcer load in stomach and small intestine. She remained in clinical remission after 1 year of treatment. Case 2: A 61-year-old man admitted for gastric outlet obstruction. Upper endoscopy showed diffuse ulcers in antrum and proximal duodenum with stenosis. Gastrin, H. pylori serology and quantiferon TB were negative. CT abdomen showed thickened second portion of duodenum; colonoscopy showed ileitis and colon was normal. IBD serology (Prometheus) was consistent with Crohn's disease. He responded to pantoprazole with improvement of duodenal ulcers and stenosis but at least one-third of the antrum showed persistent dimunitive ulcers. Focally enhanced gastritis was seen on antral biopsies. Patient remained symptomatic with poor nutritional status. Infliximab was started and patient has been doing well on therapy. Symptomatic gastroduodenal Crohn's disease may be wrongly diagnosed as peptic ulcer disease delaying appropriate medical treatment. Presence of focally enhanced gastritis may serve as a histological marker for Crohn's disease. Further clinical investigation in mucosal histological marker is warranted in the subset of H. pylori negative patients with dyspepsia/recurrent peptic ulcer disease whom may have underlying immune dysfunction and elevated anti TNF.

Pyloric stenosis associated Crohn's disease responding to adalimumab therapy

Gastroduodenal Crohn's disease (CD) is rare and the response to standard medical therapy is often poor. Anti-tumor necrosis factor therapy has revolutionised the treatment of CD. We present a patient with pyloric stenosis associated with CD which improved with Adalimumab therapy. We recommend considering anti-tumor necrosis factor therapy in symptomatic gastroduodenal CD.

Gastro-duodenal Crohn disease in a child presenting with cyclical vomiting

The Journal is the primary organ of Continuing Paediatric Medical Education in Sri Lanka. The journal also has a website. Free full text access is available for all readers.The Sri Lanka Journal of Child Health is now indexed in SciVerse Scopus (Source Record ID 19900193609), Index Medicus for South-East Asia Region (IMSEAR), CABI (Centre for Agriculture and Bioscience International Global Health Database), DOAJ and is available in Google, as well as Google Scholar.The policies of the journal are modelled on the Committee on Publication Ethics (COPE) Guidelines on Principles of Transparency and Best Practice in Scholarly Publishing. Sri Lanka Journal of Child Health is recognised by the International Committee of Medical Journal Editors (ICMJE) as a publication following the ICMJE Recommendations.

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

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.

Appropriate management of special situations in Crohn's disease (upper gastro-intestinal; extra-intestinal manifestations; drug safety during pregnancy and breastfeeding): Results of a multidisciplinary international expert panel—EPACT II

Introduction High-grade evidence is lacking for most therapeutic decisions in Crohn's disease. Appropriateness criteria were developed for upper gastro-intestinal, extra-intestinal manifestations and drug safety during conception, pregnancy and breastfeeding in patients with Crohn's disease, to assist the physician in clinical decision making. Methods The European Panel on the Appropriateness of Crohn's Disease Therapy (EPACT II), a multidisciplinary international European expert panel, rated clinical scenarios based on evidence from the published literature and panelists' own clinical expertise. Median ratings (on a 9-point scale) were stratified into three categories: appropriate (7–9), uncertain (4–6 with or without disagreement) and inappropriate (1–3). Experts were also asked to rank appropriate medications by priority. Results Proton pump inhibitors, steroids, azathioprine/6-mercaptopurine and infliximab are appropriate for upper gastro-duodenal Crohn's disease; for stenosis, endoscopic balloon dilation is the first-line therapy, although surgery is also appropriate. Ursodeoxycholic acid is the only appropriate treatment for primary sclerosing cholangitis. Infliximab is appropriate for Pyoderma gangrenosum, ankylosing spondylitis and uveitis, steroids for Pyoderma gangrenosum and ankylosing spondylitis, adalimumab for Pyoderma gangrenosum and ankylosing spondylitis, cyclosporine-A/tacrolimus for Pyoderma gangrenosum. Mesalamine, sulfasalazine, prednisone, azathioprine/6-mercaptopurine, ciprofloxacin, and probiotics, may be administered safely during pregnancy or for patients wishing to conceive, with the exception that male patients considering conception should avoid sulfasalazine. Metronidazol is considered safe in the 2nd and 3rd trimesters whereas infliximab is rated safe in the 1st trimester but uncertain in the 2nd and 3rd trimesters. Methotrexate is always contraindicated at conception, during pregnancy or during breastfeeding, due to its known teratogenicity. Mesalamine, prednisone, probiotics and infliximab are considered safe during breastfeeding. Conclusion EPACT II recommendations are freely available online ( www.epact.ch). The validity of these criteria should now be tested by prospective evaluation.

Screening for Celiac Disease in Short Bowel Syndrome

Malabsorptive diarrhea due to short bowel syndrome (SBS) results in nutrition compromise, often requiring parenteral nutrition (PN). Activation of latent celiac disease can occur after gastrointestinal surgery. Our objective was to determine whether undiagnosed celiac disease contributes to malabsorption in patients with SBS. Adult subjects with SBS were tested for celiac disease using immunoglobulin A (IgA) tissue transglutaminase (TTG) antibody and total IgA level. Subjects with an elevated IgA tissue transglutaminase were offered upper endoscopy with biopsies of the duodenum. Eighteen subjects were enrolled. The subjects were predominantly white, and the most common cause of SBS was Crohn's disease. The mean length of remaining small bowel was 93.1 +/- 54.6 cm. All subjects had undergone surgeries, resulting in loss of the ileocecal valve. Five subjects were found to have an elevated total IgA. A single patient was found to have an elevated IgA tissue transglutaminase antibody, and subsequent endoscopy demonstrated active gastroduodenal Crohn's disease, without features of celiac disease. No subjects were IgA deficient, but 5 subjects were found to have elevated IgA levels. Undiagnosed celiac disease did not contribute to malabsorption in our small cohort of predominantly white SBS patients. Larger studies are warranted.

Gastroduodenal Crohn's Disease Is Associated With NOD2/CARD15Gene Polymorphisms, Particularly L1007PHomozygosity

Limited data exist on the specific association between gastroduodenal Crohn's disease (GDCD) and NOD2/CARD15 gene polymorphisms. The aim of this study was to assess the association between NOD2 polymorphisms and GDCD, and to assess the specific association between each of the 3 major allelic variants G908R, L1007P, and R702W and the clinical features of Crohn's disease. We retrospectively reviewed the records of 202 patients with confirmed Crohn's disease and complete data was performed. Seventy-one patients (35%) had at least 1 allelic variant: 55 had 1 variant, 4 were homozygous for L1007fs, 2 homozygous for R702W, and 10 were compound heterozygous. Eighteen patients with confirmed GDCD were identified; 10 (56%) had wild type, 4 (22%) had 1 variant, and 4 (22%) had 2 allelic variants (2 were L1007P homozygous and 2 compound heterozygous). Compared to patients without gastroduodenal involvement, those with GDCD were more likely to have 2 allelic variants (22% vs. 6%; odds ratio [OR] 2.7; 95% confidence interval [CI] 1.6-7.3) and to be homozygous for L1007P (11% vs. 1%; OR 5.2; 95% CI 2.5-9.4). G908R heterozygosity was associated with ileal involvement (OR 1.4; 95% CI 1.1-2.9) and smoking habits (OR 2.4; 95% CI 1.2-3.8), whereas L1007P homozygosity was associated with GDCD (OR 5.8; 95% CI 2.6-10.8). L1007P variation was associated with younger age at diagnosis as well. There was no specific association between R702W homo- or heterozygosity and any of the characteristics examined. In conclusion, GDCD is associated with double dose of the NOD2/CARD15 gene variants, particularly L1007P homozygosity. There is evidence of specific variant-phenotype associations. G908R heterozygosity is associated with ileal involvement and smoking, whereas L1007P homozygosity is strongly associated with GDCD and younger age at diagnosis.

Gastroduodenal Crohn's Disease

Crohn's disease is one of 2 archetypes of chronic idiopathic inflammatory bowel disease, the other being ulcerative colitis. Crohn's disease is defined by chronic inflammation that may involve any site of the gastrointestinal tract, from mouth to anus, most commonly the terminal ileum and proximal colon (1). Rarely, Crohn's disease may affect the stomach and duodenum. The unusual clinical features of gastroduodenal Crohn's disease and the various treatments available, including medical, endoscopic, and surgical, are discussed in this article.

Helicobacter pylori negative ulcer disease

The proportion of ulcer patients without evidence of Helicobacter pylori infection varies considerably in different parts of the world, which may be explained by the different prevalence of H. pylori infection in the background population. In any ulcer patient with an H. pylori-negative test, it is important to consider that the test may be falsely negative due to treatment with antibiotics, bismuth preparations, or potent acid inhibitory therapy. The commonest cause of true H. pylori-negative ulcers is usage of nonsteroidal anti-inflammatory drugs, so patients should be carefully questioned about such therapy. Rarer causes of H. pylori-negative duodenal ulcers include gastroduodenal Crohn's disease and Zollinger-Ellison syndrome. About 50% of H. pylori-negative duodenal ulcer patients have no apparent explanation for the ulcer disease. A proportion of these patients have increased gastric acid secretion and increased duodenal acid load, which is likely to be of pathogenic significance. H. pylori-negative ulcers are more difficult to control with antisecretory drugs.

A CASE OF THE DUODENAL CROHN'S DISEASE PRESENTED WITH DUODENAL STENOSIS IN THE ELDERLY

There have been only 26 cases of gastroduodenal Crohn's disease with stenotic lesion reported in Japan. We report a case of resected duodenal Crohn's disease presented with duodenal stenosis in an elderly patient. A 66-year-old man had begun to suffer from nausea and vomiting ten years before. An endoscopic examination found a diffusely granular appearance in the bulbs, and the endoscope could not pass through the duodenum because of a stenosis. An upper GI series examination revealed a marked circular constriction about 3cm in length between the pyloric ring and the second portion of the duodenum. Partial resection of the stomach and duodenum was performed. The resected specimen showed a longitudinal ulceration and a cobblestone appearance in the duodenum. Histopathological examination showed the non-caseating granulomas scattered through the bowel. The patient is alive and well without any signs of recurrence one year after surgery.

An Audit of Gastroduodenal Crohn Disease: Clinicopathologic Features and Management

Background: This study was undertaken to assess the clinicopathologic features and management of gastroduodenal Crohn disease. Methods: The medical records of 54 patients with gastroduodenal Crohn disease treated between 1958 and 1997 were reviewed. Results: Gastroduodenal Crohn disease occurred in association with disease elsewhere in 52 patients (96%). The commonest pathology was stricture (n = 41), followed by ulceration (n = 4) and duodenocutaneous fistula (n = 2). Medical treatment was initially attempted in 31 patients, of whom 12 required no surgical treatment for gastroduodenal disease. Nineteen patients required surgery for gastroduodenal obstruction or fistula despite medical treatment. Overall, 33 patients (61%) required surgery; the indication was obstruction in 30, duodenocutaneous fistula in 2, and bleeding in 1. There was one postoperative death because of persistent bleeding and intra-abdominal sepsis after oversewing of a bleeding ulcer. In obstructive disease 16 patients were treated by bypass surgery, 10 by strictureplasty, and 4 by gastrectomy. After surgery for obstructive disease anastomotic leak developed in three patients, and persistent gastric outlet obstruction was seen in six patients. In the long term 11 patients required reoperation for anastomotic obstruction (n = 9) or stomal ulceration (n = 2). For duodenocutaneous fistula one patient underwent simple closure of fistula, and the other patient duodenojejunostomy. Both of these patients developed an intra-abdominal abscess without evidence of leak. There has been no fistula recurrence. Conclusions: Gastroduodenal Crohn disease is a complex and difficult problem that is associated with serious complications and need for reoperation.

Long-term outcome of endoscopic balloon dilation in obstructive gastroduodenal Crohn's disease.

Although balloon dilation is widely used in nonmalignant pyloric stenosis, little information is available on either the short-term or long-term results of this type of therapy in patients with obstructive gastroduodenal Crohn's disease. Five patients with Crohn's disease who had obstructive gastroduodenal lesions were treated using endoscopic balloon dilation. All the initial dilations successfully provided symptomatic relief. However, three of the five patients developed recurrent obstructive symptoms during a mean follow-up period of 4.2 years. Due to symptomatic recurrence, three patients required successive or regularly scheduled repeat balloon dilations, which were successful without any complications, and all of the patients were able to avoid surgical intervention. These results suggest that over a prolonged period of time, patients who have undergone balloon dilation for obstructive gastroduodenal Crohn's disease have a high rate of recurrence of symptomatic gastric obstruction. However, repeat dilations are successful in continuing to prevent the need for surgery.

Gastroduodenal Crohn's disease: The focus is on focality

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Gastroduodenal Crohn's disease: Report of a case and review of Japanese literatures

Gastroduodenal Crohn's disease: Report of a case and review of Japanese literatures

幽門狭窄により胃切除術を行った胃・十二指腸および回盲部Ｃｒｏｈｎ病の１例

幽門狭窄により胃切除術を行った胃・十二指腸および回盲部Ｃｒｏｈｎ病の１例

Perianal complications of pediatric Crohn's disease

The management of perianal disease (PD) in children with Crohn's disease was reviewed. Of 325 patients (184 boys), 200 (62%) developed PD. The mean age at diagnosis of Crohn's disease was 11.2 years (range, 5 to 17 years). Skin tags were present in 114 (35%) patients, fissures in 165 (51%), fistulas in 41 (15%), and perirectal abscesses in 47 (13%). One hundred fifty-three patients had PD as one of the first symptoms; 71 of these had complete remission of PD and the remaining 82 had chronic symptoms. Forty-two patients were intially free of PD, only to develop it later. PD occurred in 50% of patients with gastroduodenal Crohn's disease, 57% with jejunal, 68% with ileal, 64% with ileocecal, 60% with ileocolic, and 51% with colonic. Local minor operation was necessary in 38 (12%) patients, fistulotomy in 12, and abscess drainage in 26. Four patients required either intestinal resection and/or enterostomy for progressive PD. Fifty-three patients received metronidazole, with amelioration in 38. It is concluded that PD is a common complication of Crohn's disease in children and adolescents. Its presentation may antedate that of the primary disease. Most PD follows a benign course. There is a limited role for operation, but a need for meticulous perineal care and a potential benefit with metronidazole therapy. We advocate conservatism in the management of perianal complications of Crohn's disease in pediatric patients.