crohn’s disease of the esophagus: three cases and a ...tive disease of the esophagus tended to be...

The prevalence of esophageal involvement in Crohn’sdisease (CD) has been estimated in the literature to bebetween 1% and 2% (1). However, the pediatric literaturehas reported a prevalence of 20% to 40% when all patients

were prospectively surveyed by means of esophagogastro-duodenoscopy (EGD) during the acute phase of CD (2).Case reports are typically brief, and not all questions can beanswered by reviewing them. Three cases of esophageal CD

Can J Gastroenterol Vol 15 No 2 February 2001 117

MINI-REVIEW

Crohn’s disease of theesophagus: Three casesand a literature review

Ivan Rudolph MD, Franz Goldstein MD, Anthony J DiMarino Jr MD

This mini-review was prepared from a presentation made at the 1998 meeting of the Bockus International Society of Gastroenterology, Graz, Austria, August 31 to September 3, 1998

Division of Gastroenterology, Thomas Jefferson University, Philadelphia, Pennsylvania, USACorrespondence and reprints: Dr I Rudolph, Division of Gastroenterology and Hepatology, Thomas Jefferson University, 132 South 10th Street,

480 Main Building, Philadelphia, Pennsylvania 19107-5244, USA. Telephone 215-955-8900, fax 215-955-0872, e-mail [email protected]

Received for publication July 6, 1999. Accepted July 12, 1999

I Rudolph, F Goldstein, AJ DiMarino Jr. Crohn’s disease ofthe esophagus: Three cases and a literature review. Can JGastroenterol 2001;15(2):117-122. Three cases of esophagealCrohn’s disease (CD) are described, each with dysphagia and/orodynophagia caused by esophageal ulceration. All three patientshad associated ileocolitis. One patient followed for a prolongedperiod responded to treatment with sulfasalazine and pred-nisone. A computer search back to 1967 produced 72 additionalcases of esophageal CD. Among these 75 patients (total), whowere, on average, 34 years old, esophageal disease was the pre-senting disease symptom in 41 patients (55%). The diagnosiswas difficult in 13 patients, in whom no distal bowel disease wasdetected at the time of initial esophageal presentation. The mostcommon presentation was dysphagia associated with aphthousor deeper ulcerations (52 patients). In 11 of these patients, oralaphthous ulcerations were also present. Esophageal stenosis orfistulas to surrounding structures were present in 27 patients andled to surgery in 17 patients. Most of the unfavourable outcomeswere in this group of 27 patients with esophageal complications,including five deaths. Fourteen additional patients required sur-gery for CD of other areas. Responses of uncomplicated ulcera-tive disease of the esophagus tended to be favourable if themedical regimen included prednisone. Clinical patterns ofesophageal CD were divided into three categories: ulcerative,stenosing and asymptomatic (acute disease in children).

Key Words: Crohn’s disease; Esophageal disease

Trois cas de maladie de Crohn de l'œsophageet examen de la documentationRÉSUMÉ : Voici trois cas de maladie de Crohn (MC) de l'œsophagecaractérisée par une dysphagie et/ou une odynophagie causée par uneulcération œsophagienne. Les trois patients présentaient également uneiléo-colite. Le suivi prolongé d'un patient a montré que ce dernier avaitbien réagi au traitement à la sulfasalazine et à la prednisone. Unerecherche informatisée des dossiers depuis 1967 a permis de relever72 cas de MC de l'œsophage. Un trouble de l'œsophage a été le premiersigne de la maladie chez 41 des 75 patients (55 %), âgés en moyenne de34 ans. Le diagnostic a été difficile à poser chez 13 d'entre eux étant don-né qu'aucune maladie intestinale distale n'avait été décelée au momentde l'apparition du premier signe de trouble œsophagien. La manifesta-tion la plus courante a été une dysphagie associée à une ulcération aph-teuse ou profonde (52 patients); onze souffraient également d'aphtesbuccaux. Vingt-sept patients présentaient une sténose œsophagienne oudes fistules et 17 d'entre eux ont dû être opérés. La plupart des résultatsnégatifs, dont cinq morts, ont été observés dans le groupe de patientsprésentant des complications œsophagiennes. Quatorze autres patientsont été opérés pour une MC touchant d'autres régions. Le traitement dela forme non compliquée de l'ulcération œsophagienne semblait donnerde bons résultats si celui-ci comprenait de la prednisone. Les signes clin-iques de la MC de l'œsophage ont été divisés en trois catégories : ulcères,sténose et absence de symptômes (maladie aiguë chez les enfants).

recently encountered in the authors’ practices aredescribed, together with a review of the pertinent litera-ture.

CASE 1A 24-year-old married woman was seen in February 1998;her chief complaint was odynophagia. She had sufferedfrom prolonged heartburn. Treatment with H2-receptorblockers, and later with proton pump inhibitors, producedonly minor symptom relief. Subsequently, odynophagiadeveloped, brought on by swallowing any food or even sali-va. Avoidance of spicy foods produced minimal benefit.Past medical history recalled by the patient included ‘func-tional’ gastrointestinal problems in 1986, when the patientwas 12 years old. Unrelated events also recalled includedbouts of cystitis, and asthma treated with oral prednisoneand an albuterol inhaler. On physical examination, thepatient appeared well developed and nourished, vital signswere normal and general examination failed to show anyabnormalities. Because of the odynophagia, EGD was per-formed. EGD revealed three distinct esophageal ulcers,each appearing as a sharply demarcated, red, approximately5 mm round area in the lower esophagus surrounded bynormal-appearing mucosa (Figure 1). The Z-line was dis-tinct without clinically apparent esophagitis or stricture.The stomach and duodenum appeared normal. Biopsiesfrom the lower esophagus revealed dense lymphocytic infil-trates in several areas and ulcerations in others. Granu-lomas were not found.

The patient’s mother recalled that her daughter hadbeen suspected of having CD in 1986. Records and x-rayswere retrieved. The patient had presented in 1986 withdiarrhea and abdominal pain. Barium contrast studies ofthe gastrointestinal tract were reviewed and showed a dis-tinct segment of ileocolitis involving about 6 cm of the ter-minal ileum and 3 cm of the adjacent cecum. The EGD in

1986 also showed antral gastritis, with biopsies confirmingnonspecific inflammation of the prepyloric area withHelicobacter pylori positivity. Treatment with ampicillinseemed to help. Follow-up radiographs in 1989 showed par-tial improvement of the ileal changes. Repeat radiographsobtained in 1998 showed minimal residual scarring of theterminal ileum. Treatment was initiated with mesalamine,but the patient was lost to follow-up before the response totreatment could be evaluated.

The interpretation of events from 1986, 1989 and 1998suggests that they were due to CD, and that the recent pre-dominant problem is esophageal CD with multiple ulcersand corresponding symptoms.

CASE 2A 28-year-old married woman presented in April, 1991with three weeks of abdominal cramps and up to six waterystools per day. Five days before her visit, she developed asore throat, and her husband, who was a physician, notedaphthous ulcers in her mouth. The patient developed dys-phagia and odynophagia by the time of her evaluation. Shehad fevers with temperatures of up to 102°C. Past medicalhistory included uveitis treated at a university clinic withsteroid eye drops.

On examination, the patient’s blood pressure was100/70 mmHg and her pulse was 112 beats/min. On the hardpalate and buccal surfaces, multiple white papules – someulcerated – were noted. The remainder of the examinationwas unremarkable, except for a grade 2 systolic murmur at theapex and mild, lower to mid-abdominal tenderness. On theEGD, multiple small aphthous ulcerations on slightly elevat-ed bases were noted, which were similar to the ones in themouth and measured from 2 mm to 6 mm in diameter(Figure 2). Similar lesions were also found diffusely distrib-uted in the stomach and proximal duodenum. The duodenalloop was normal. Biopsies and brushings taken from the

Rudolph et al

Can J Gastroenterol Vol 15 No 2 February 2001118

Figure 1) Discrete small ulcerations in the distal esophagus of thepatient described in case 1. Markers indicate two ulcers

Figure 2) Multiple aphthous ulcers in the mid- and distal esophagus ofthe patient described in case 2

ulcers failed to show viral inclusions but did show acute andchronic superficial gastritis and esophagitis, with some gran-ulation tissue and scattered ulcerations. Flexible sigmoi-doscopy, done at the same time, showed erythema andshallow irregular ulcerations scattered over the distal 35 cm.Biopsies revealed acute and chronic inflammation with cryptabscesses, consistent with inflammatory bowel disease.Granuloma formation in submucosal lymphoid aggregateswas suggested.

The patient was treated with sulfasalazine 2 g/day andprednisone 40 mg/day, followed by a dramatic response –the disappearance of dysphagia within a few days andimprovement in the diarrhea. When the patient was seen inthe office three weeks later, the aphthous ulcerations of themouth were no longer seen, and she reported to be free ofdysphagia and diarrhea. Stool cultures and examinations forova and parasites were reported to be negative. Prednisonewas tapered to nothing over a 10-week period, but sul-fasalazine was continued. Pancolonoscopy, done in thishealing phase, showed mild erythema in the right colon andnodularity in the distal 30 cm of the left colon. Biopsiesfrom the right colon showed acute and chronic colitis,while biopsies from the left colon showed focal lymphoidaggregates with early changes of granuloma.

The patient became pregnant shortly after going intoremission and delivered healthy twins in January, 1993.Sulfasalazine was stopped seven months later, and thepatient remained well for another 10 months, when shedeveloped recurrent diarrhea. She again responded to sul-fasalazine and prednisone, the latter being tapered over thenext two months. With sulfasalazine alone, the patientremained in remission for two years. Sulfasalazine was againstopped, followed by another relapse four months later.Both prednisone and sulfasalazine were restarted with aprompt response. After tapering prednisone again, thepatient continued in remission while on sulfasalazine alonefor the next eight months of observation. None of therelapses were accompanied by esophageal symptoms.

CASE 3A 42-year-old man was evaluated in a gastrointestinal clinicfor a 20-year history of Crohn’s disease, initially involvingthe terminal ileum. The diagnosis was established withexploratory laparotomy for what was thought to be acuteappendicitis in 1979, at age 22 years. His initial presentationwas severe right lower quadrant pain, with elevation of hiswhite blood cell count to 14,000. After a period of observa-tion, it was thought that he had acute appendicitis and, atthe time of laparotomy, was found to have congestion andthickening of the terminal ileum with a large thickenedmesentery and an enlarged mesenteric lymph node.Pathology revealed increased lymphocytes with no granulo-mas in the mesenteric lymph nodes and a normal appendix.A subsequent small bowel series revealed 5 cm to 6 cm ofterminal ileal narrowing, consistent with Crohn’s disease.

In 1984, the patient developed perianal burning andpain with defecation. He had recurrent fissures involving

the anal sphincteric region and was seen by his attendinggastroenterologist; he was subsequently referred to a col-orectal surgeon. A fissure from the Crohn’s disease was not-ed, and local care, incision and drainage were judiciouslyperformed over the next several years.

In 1985, an air contrast barium enema revealed scarringof the ileocecal valve with aphthous ulcerations consistentwith Crohn’s disease.

In 1986, the patient described dysphagia, particularly withsolid foods, and was evaluated by a gastroenterologist withupper endoscopy. Findings at that time revealed an exudativedistal esophageal mucosa with multiple small ulcerations.The amount of esophageal involvement was approximately2 cm to 3 cm in length. He was treated with high dose H2-receptor antagonists without improvement. His esophagealulcerations were re-evaluated by two subsequent gastroen-terologists – all within an 18-month period. Despite inten-sive antisecretory therapy, the esophageal ulcerationspersisted. Several biopsies of the area revealed lymphocyticinfiltrate with occasional eosinophils. No granulomas wereidentified. He initially required balloon esophageal dilation,and periodically since 1986, he has required Maloneybougienage therapy for recurrent dysphagia and odynopha-gia. His esophageal ulcerations persisted despite proton pumpinhibitor therapy in the form of omeprazole 40 mg bid, H2-receptor antagonists in the form of ranitidine or famotidine40 mg bid, and antacids. The dysphagia and perianal discom-fort with defecation improved with azathioprine therapy300 mg/day. However, he developed severe leukopenia, andthis medication was withdrawn.

Intermittent therapy with metronidazole, ciprofloxacin,corticosteroids and 5-aminosalicylic acid preparations havenot significantly altered the patient’s recurrent symptoms ofodynophagia and dysphagia for solids. He requires periodicesophageal dilations with Maloney tapered bougies.Successful dilations are completed to an approximately1.6 cm esophageal lumen, performed approximately everythree to six months, in conjunction with therapy to decreaseacid secretion in the form of proton pump inhibitors, H2-receptor antagonists and sucralfate suspension.

He is relatively asymptomatic from a lower gastrointesti-nal viewpoint, having approximately one or two formedbowel movements per day.

LITERATURE REVIEWReview of the English language literature using a computersearch of MEDLINE for the years 1967 to 1998 yieldedreports for 72 patients with esophageal CD (1,3-40). Afteradding the present three cases, data of all 75 patients weretabulated by age, sex, whether CD at other sites predatedthe esophageal presentation and which sites, in addition tothe esophagus, were involved. Data were also tabulated onthe endoscopic and radiographic appearance of the esopha-gus, and whether granulomas were found in biopsies andother tissue specimens. Finally, available data on medicaland surgical treatments and clinical outcome were analyzed.

Crohn’s disease of the esophagus


RESULTSAmong the 75 patients reviewed, including the three presentcases, 34 were male and 41 female – an insignificant differ-ence. The average age of the patients at diagnosis of eso-phageal CD was 34 years; this average masks a substantialnumber of patients diagnosed in childhood, most of whomwere reported relatively recently. In 13 patients (17.5%), theinitial diagnosis of CD was made by the presence of esoph-ageal manifestations alone. In an additional 28 patients(37.8%), esophageal involvement, together with involve-ment more distally in the gut, was present on initial diagno-sis. Among the 13 patients with esophageal disease only onpresentation, two developed more distal bowel involvementduring the four years of follow-up (9,25). With the short fol-low-ups available in many cases, it was not possible to deter-mine whether subsequent flare-ups were associated withmore distal bowel disease.

The distribution of involved segments of the gut inpatients with and without prior diagnosis of CD showedno significant differences in disease distribution (Table 1).Extraintestinal manifestations (not listed) were present in20 patients (27%), and involved the eyes, joints and skin.

The coexistence of oral and esophageal lesions wasstriking. Of the 20 patients with oral disease, 11 had simi-larly appearing aphthous ulcers in the esophagus. Theremaining nine patients had variable esophageal lesionsranging from deeper ulcerations to strictures. Table 2 liststhe combined endoscopic and radiographic appearance ofthe esophageal CD in the group of 75 patients. The largestnumber of patients presented with aphthous or deeperulcerations; smaller numbers presented with nodularity orerythema, strictures, fistulas and, in two instances, pseudo-polyps (13,19).

The histology of esophageal tissue recovered from 69patients showed acute and chronic inflammation, ulcera-tions, and occasional fibrosis and transmural involvementin patients who had surgical, full-thickness biopsies. Classicgranulomas were found in 27 patients (39%).

Esophageal complications in the form of stenosis, fistulaor both were present in 27 patients; their mean age was 47years – considerably older than the mean age of the entiregroup. This suggests that these patients had longstandingdisease progressing to the complications listed. In four

patients, fistulous drainage was documented to a pleuralcavity or bronchus (15,16,25,32). Seventeen of the 27patients with fistulas and/or stenosis required surgery. Ofthese, 13 were improved while four failed to improve,including three who died (34,40). Of the 10 remainingpatients treated medically, five improved and five failed toimprove, including two deaths (16,32). Among the 75patients (total) there were nine deaths, and only four weredue to causes other than esophageal complications, includ-ing fulminant disease with bowel perforation (34), multipleresections and their nutritional consequences (28,31), andsepsis (10).

Seventeen of the 75 patients were treated with surgeryalone. Fourteen additional patients underwent surgerytogether with various medical interventions. Thirty-fivewere treated with medical or pharmacological therapy alone.In nine cases, no details of therapy were provided. Amongthe 49 patients treated medically, 43 received corticosteroidsalone or in combination with aminosalicylates, and sixreceived aminosalicylates only. Ten patients were also treat-ed with other modalities including bougienage, acid suppres-sants or 6-mercaptopurine (five patients). Steroid treatmentgenerally produced short term improvement, but long termresults could not be noted. Responses to drugs other thansteroids or immunomodulators were usually poor, although,in case 2 in the present report, sulfasalazine seemed to pro-vide some benefit. Some patients showed symptomaticimprovement with acid suppression and/or bougienage, butno esophageal healing could be seen.

Eighteen patients had bowel surgery either before orafter the discovery of esophageal disease. Resolution ofbowel disease and improvement in unresected esophagealdisease was reported in one patient (30). Another (18) hadesophageal improvement while on steroids, which weretapered four months postoperatively. In 16 other patients,esophageal disease developed after bowel resection oresophageal disease progressed despite segmental resection ofintestinal CD (8-10,13,16,19,20,25,28,29,31-34).

DISCUSSIONThe esophagus is among the least common segments of thedigestive tube involved in CD. We were able to find only 72cases reported in the literature and added the three present

Rudolph et al


cases. Very few cases were reported before 1967, althoughthe initial description of esophageal CD is attributed toFranklin and Taylor in 1950 (41). Undoubtedly, many morecases encountered have not been reported. With the wideruse of upper gastrointestinal endoscopy in recent years, andwith prospective studies in patients with CD, esophagealinvolvement has been observed in up to 43% of childrenwith CD (2). Lenaerts et al (42) surveyed 230 children andadolescents with CD for an average of 6.6 years. Thirty percent of these had disease of the esophagus, stomach or duo-denum. Although 69 of the 230 patients had upper gas-trointestinal symptoms, 13 had normal x-rays, and onlyendoscopy revealed lesions compatible with CD. Korelitzet al (43) performed routine upper endoscopies and biopsiesof the esophagus, stomach and duodenum in 45 patientswith CD, and normal upper gastrointestinal x-rays. Theyfound diagnostic biopsies in 11 patients and nonspecificmicroscopic changes in 19 patients; among the patientswith abnormal biopsies were 11 patients with endoscopical-ly normal-appearing mucosa. These studies illustrate thefrequent presence of upper gastrointestinal lesions in theabsence of symptoms and sometimes in the absence of endo-scopic abnormalities. There seems to be a major differencein the prevalence of esophageal CD between children andadults. Because CD is a chronic, often lifelong disease, thedifference in the frequency of esophageal involvementbetween children and adults invites speculation as to thecause of this discrepancy. Many patients with esophagealCD were reported to have aphthous ulcerations, generallyregarded as very early manifestations of CD and oftenobserved at onset of the disease. With later progression ofthe disease, the aphthous ulcers of the esophagus may dis-appear. However, in the present literative review, CD of thecolon, ileum or gastroduodenal segment precededesophageal involvement in 33 patients by up to 24 years,perhaps showing in yet another way the wide range of man-ifestations of this baffling disease. When esophageal CDwas observed in adults, it often presented with stenoses andfistulas, which are generally considered complications oflongstanding CD.

Most patients with esophageal CD present withodynophagia and/or dysphagia. Bleeding and fistulizationoccur rarely; however, when present, they indicate a morethreatening aspect of the disease. Fistulas to bronchi orpleural spaces usually require surgical intervention, andcarry a substantial risk of morbidity and mortality. Threedeaths occurred in the group of 17 patients who were oper-ated on for esophageal fistulas and/or stenosis, and twodeaths occurred in patients treated medically for this com-plication. Only four additional deaths occurred among theentire group of 75 patients reviewed. The use of the newerexpandable metal stents may decrease the need for surgery,and complications could perhaps be reduced.

The diagnosis of esophageal CD can be suspected if dys-phagia or odynophagia is present, but these are not specificfor CD. In patients with CD known to exist in other gas-trointestinal segments, the right diagnosis should be sug-

gested but needs confirmation by means of endoscopy andtissue examination. In most cases, endoscopic findingsalone are not specific; histological changes, more likelythan not, fail to show granulomas and can only be consid-ered compatible with CD. Yet with the exclusion of otherspecific diagnoses, and in the proper clinical setting, thediagnosis reasonably can be made with these tests.

The differential diagnosis of CD of the esophagus is tabu-lated in Table 3. In the presence of stenosis, severe refluxesophagitis or carcinoma ranks high among diagnostic possi-bilities. The additional presence of fistulas would especiallysuggest malignancy. Aphthous or other superficial ulcera-tions would require differentiation from viral infections,especially the herpes simplex virus and the cytomegalovirus;single or multiple ulcers would also have to be differentiatedfrom drug-induced lesions. Behçet’s syndrome would posediagnostic difficulties in areas where this disease is common(eg, Turkey – it is rarely encountered in the United States).In this syndrome, overlapping involvement of the eyes,mouth, skin, joints and gastrointestinal tract occurs. Twocases of Behçet’s syndrome involving the esophagus andileum were reported by Vlyman and Moskowitz (44). Twoother cases of colonic disease indistinguishable from CDwere also reported (45,46). Epidermolysis bullosa acquisita isanother autoimmune disease that can be associated withesophageal strictures. Thirteen cases have been reported inassociation with CD (47). The diagnosis is made by immu-noelectron microscopy of the skin lesions demonstratingimmunoglobulin G and C-3 deposits.

There is little information on appropriate treatment. Nocontrolled therapeutic trials have been reported dealingwith esophageal CD, and its relative infrequency wouldmake such trials difficult to perform. Observational datasuggest therapeutic benefits primarily from corticosteroidsgiven over short periods of time. Virtually all pharmacolog-ical agents used for inflammatory bowel disease have beenused in the treatment of CD, including aminosalicylatesand immunomodulators. Removal of a stenotic segment ofesophagus refractory to medical treatment and frequentbougienage were the most common reasons for surgeryamong the patients reviewed. The relative frequency of sur-gery and its high complication rate are noted. Surgicalresections of diseased distal gut segments failed to affect thecourse of esophageal CD in 16 of 18 patients.

Crohn’s disease of the esophagus


Prognosis on medical therapy was addressed by D’Haenset al (3), who followed 14 patients for an average of six years.Twelve patients were treated with prednisone and two weretreated with aminosalicylates plus antibiotics. In eightpatients, there was complete healing of the esophageal dis-ease despite further exacerbations of CD elsewhere. Thesedata, as well as the higher prevalence of esophageal CD inchildren compared with adults, suggest that spontaneousimprovement of esophageal CD occurs commonly.

Analysis of the collected data suggests that esophagealCD should be categorized into three broad clinical presenta-tions. The most common presentation is dysphagia orodynophagia accompanied by aphthous or deeper ulcera-tions, usually associated with acute exacerbations of the CD.Patients may also present with strictures (stenosis) with orwithout fistula, usually at an older age and with a history ofchronic disease. Patients with esophageal CD may be asymp-tomatic but frequently have symptomatic CD in more distalgut segments. This would include patients with normalendoscopy but abnormal histology. This presentation wouldexplain the high prevalence of esophageal CD reported inchildren with symptomatic CD distally, but undergoingEGD and biopsy.

ACKNOWLEDGEMENTS: The authors thank Dr StuartEisenberg for providing the information for case 2 and CelesteHodges, Librarian, for providing the literature searc

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Gastroenterology Research and Practice


Parkinson’s Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com

crohn’s disease of the esophagus: three cases and a ...tive disease of the esophagus tended to be...

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