Edward Loftus, MD, on Upper GI Crohn's Disease

Dr Loftus explains how Crohn's disease can affect the upper gastrointestinal system, from the mouth to the duodenum, and the options for treating this uncommon presentation.

Edward V. Loftus, Jr., M.D. is the Maxine and Jack Zarrow Family Professor of Gastroenterology Specifically in IBD at the Mayo Clinic College of Medicine and Science in Rochester, Minnesota.

TRANSCRIPT:

Hi, I am Ed Loftus. I'm from Mayo Clinic in Rochester, Minnesota. I'm here at Advances in IBD, and I'll be giving a talk later today on Uupper GI Crohn's disease. So upper GI Crohn's disease is fairly uncommon. It does seem to be more frequently diagnosed in pediatric age patients for reasons that are unclear and we define upper GI Crohn's as anything proximal to the ligament of Treitz. There's also, of course, more extensive small bowel disease, jejunal disease, but that really fits more in with lower GI Crohn's.

Most people with upper GI Crohn's also have lower GI Crohn's, but there are rare cases, probably much less than 5%, where you can see isolated upper GI Crohn's. And we'll start with the most common, which is gastroduodenal, so involving either the stomach or the duodenum. And this can manifest in many different ways. It can look like erythema, friability, erosions, ulcers, strictures. Think about it— the duodenum is probably the most common site for stricturing disease because it has a narrow diameter. So this can result in obstructive symptoms, nausea, vomiting, and so think any of your patients with upper GI Crohn's, you should have, I mean, upper GI symptoms, you should have a low threshold for performing upper endoscopy to investigate this.

There are some weird characteristic lesions that are sometimes seen. You'll sometimes hear the term bamboo joint appearance, and you'll see that in the fundus or body of… it's almost like a linear cobblestone of the mucosa. The treatment is generally advanced therapies. But don't forget about acid suppression because these cause ulcers and erosions and patients can get great benefit from being on a PPI or something along those lines.

In rare cases, surgery has to be done. However, if you catch gastroduodenal Crohn's early enough, you can say, for example, balloon dilate strictures. And so some patients might get pyloric stenosis that needs to be treated. Duodenal strictures can sometimes be dilated, so in some ways you can delay the need for surgery. Surgery generally is a gastrojejunostomy, so a gastro jejunal anastomosis where you bring up a loop of jejunum and bypass all the duodenal stricturing disease. In certain cases, if they're short and isolated, a duodenal strictureplasty can be done. It's generally not advised to try to do an extensive duodenal resection just because of the technical complexities of that. There are, again, reported cases of people doing very short resections in the duodenum.

Moving upstream, esophageal Crohn's, this can manifest itself in many different ways, aphthous erosions, or ulcers in the esophagus. And these don't look like peptic erosions. They're punched out ulcers or deep ulcers. This can sometimes lead to strictures, which are difficult to dilate, and sometimes fistulas. Again, these probably need to be treated aggressively medically. There's a role for dilation in some cases, and in rare instances, patients require surgery, which of course, is a complicated extensive surgery.

And then finally, there's oral Crohn's disease, and you'll hear different terms for this. You'll hear the term orofacial granulomatosis, not all OFG as it's called, is Crohn's disease, but almosat by definition Crohn's is a form of orofacial granulomatosis. This can manifest itself as a cheilitis where the lip gets swollen, and if you biopsy, it'll show granulomatous inflammation. You can see cobblestone of the oral mucosa. You can also see sort of fissuring or deep linear ulcers in the oral mucosa. Again, probably needs to be treated with advanced therapy or biologics. But don't forget about the use of dapsone. For some reason, dapsone can be helpful for some of these oral lesions.

And that's about it. So just again, if you have a patient with upper gut symptoms, have a low threshold for investigating with upper endoscopy to rule out upper gut Crohn's disease. Thanks.