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Crohn's Disease Manifesting as a Duodenal Obstruction: An Unusual Case.

ABSTRACT: We describe a case of a 31-year-old man who presented with a 3-year history of worsening upper abdominal pain, nausea, and vomiting: symptoms that were resistant to medical treatment and unexplained despite a thorough diagnostic evaluation. Then, an upper gastrointestinal series with small bowel follow-through showed proximal duodenal dilation and distal decompression of the duodenum, suggestive of a partial duodenal obstruction. An abdominal computed tomography (CT) scan revealed a transition point in the distal duodenum. At surgery, a segmental resection of the distal duodenum with a duodenojejunal anastomosis was performed. Histopathologic examination of the specimen revealed Crohn's disease. Therefore, making the diagnosis of duodenal obstruction has significant clinical implications and, in the setting of Crohn's disease, is evidence of an underlying intestinal stricture, stenotic area, or adhesion.

SUBMITTER: Shah J

PROVIDER: S-EPMC6306109 | biostudies-other | 2018 Dec

REPOSITORIES: biostudies-other

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Crohn's Disease Manifesting as a Duodenal Obstruction: An Unusual Case.

Shah Jamil J Etienne Denzil D Reddy Madhavi M Kothadia Jiten P JP Shahidullah Abul A Baqui A A M Abdullahel AAMA

Gastroenterology research 20181217 6

We describe a case of a 31-year-old man who presented with a 3-year history of worsening upper abdominal pain, nausea, and vomiting: symptoms that were resistant to medical treatment and unexplained despite a thorough diagnostic evaluation. Then, an upper gastrointestinal series with small bowel follow-through showed proximal duodenal dilation and distal decompression of the duodenum, suggestive of a partial duodenal obstruction. An abdominal computed tomography (CT) scan revealed a transition p ...[more]

PMID: 30627269

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Project description:IntroductionAnomalous congenital bands are a rare cause of intestinal obstruction, with only five previously reported cases involving duodenal obstruction. We present a fifth case of duodenal obstruction due to two congenital bands and provide a comprehensive literature review summarizing the clinical features of this condition.Case reportAn eight-year-old girl was admitted to our department with recurrent bilious vomiting and abdominal pain lasting six days. She had no significant past medical history, with no previous abdominal surgeries or trauma. Physical examination revealed abdominal tenderness and decreased bowel sounds. Contrast x-ray showed an obstructed passage of contrast through the third part of the duodenum. Abdominal ultrasound identified a strip-like hypoechoic structure compressing the third part of the duodenum. A diagnosis of duodenal obstruction was confirmed, and laparoscopic surgery combined with gastroduodenoscopy was performed. The procedure revealed two congenital bands adjacent to the duodenum: one extending from the duodenum to the transverse colon, and the other from the duodenum to the root of the mesentery. The bands were resected, and gastroduodenoscopy confirmed the resolution of the obstruction.DiscussionWe reviewed 93 cases of anomalous congenital bands, including the present one, comprising 33 adults and 60 children, with 71.0% of the cases involving males. Common symptoms included vomiting and abdominal pain, with physical examinations often showing tenderness and distension. Imaging techniques like plain x-ray, contrast x-ray, ultrasound, and computed tomography often indicated intestinal obstruction but were less effective in directly identifying congenital bands. All cases required abdominal surgery for diagnosis and treatment. Congenital bands were primarily found attached to the ileum or its mesentery and were resected in all cases, with a favorable postoperative prognosis. This case and the literature review provide valuable insights for clinical diagnosis and treatment.

Project description:BackgroundCrohn's disease with upper gastrointestinal tract involvement occurs more often in children than adults and has the potential to interfere with oral drug absorption. We aimed to compare disease outcomes in children receiving oral azathioprine for the treatment of Crohn's disease with (DP) and without (NDP) duodenal pathology at diagnosis.MethodsDuodenal villous length, body mass index (BMI), and laboratory studies were compared in DP vs. NDP during the first year post-diagnosis, using parametric/nonparametric tests and regression analysis (SAS v9.4); the data are reported as the median (interquartile range) or the mean ± standard deviation. Thiopurine metabolite concentration (pmol/8 × 108 erythrocytes) 230-400 was considered therapeutic for 6-thioguanine nucleotides (6-TGN), and >5700 was considered hepatotoxic for 6-methylmercaptopurine (6-MMPN).ResultsTwenty-six of the fifty-eight children enrolled (29 DP, 29 NDP) started azathioprine for standard medical care, including nine DP and ten NDP who had normal thiopurine methyltransferase activity. Duodenal villous length was significantly shorter in DP vs. NDP (342 ± 153 vs. 460 ± 85 μm; p < 0.001) at diagnosis; age, sex, hemoglobin, and BMI were comparable between groups. A trend toward lower 6-TGN was observed in the DP vs. NDP subset receiving azathioprine (164 (117, 271) vs. 272 (187, 331); p = 0.15). Compared to NDP, DP received significantly higher azathioprine doses (2.5 (2.3, 2.6) vs. 2.2 (2.0, 2.2) mg/kg/day; p = 0.01) and had an increased relative risk of sub-therapeutic 6-TGN. At 9 months post-diagnosis, children with DP had significantly lower hemoglobin (12.5 (11.7, 12.6) vs. 13.1 (12.7, 13.3) g/dL; p = 0.01) and BMI z-scores (-0.29 (-0.93, -0.11) vs. 0.88 (0.53, 0.99); p = 0.02) than children with NDP.ConclusionFor children with Crohn's disease, duodenal pathology, marked by villous blunting, increased the risk of sub-therapeutic 6-TGN levels, despite higher azathioprine dosing during the first year post-diagnosis. Lower hemoglobin and BMI z-scores at 9 months post-diagnosis suggest the impaired absorption/bioavailability of nutrients, as well as oral drugs, in children with duodenal disease.

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Crohn's Disease Manifesting as a Duodenal Obstruction: An Unusual Case.

Publications

Crohn's Disease Manifesting as a Duodenal Obstruction: An Unusual Case.

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