Fig. 7.1
A discrete esophageal ulcer in a patient with Crohn’s disease
The incidence of gastric and duodenal CD varies greatly in series of patients with CD, ranging from 0.5 % to 4 %. Many patients do not have endoscopically detectable lesions in the stomach and duodenum, although examination of biopsies for normal-looking mucosa does reveal histopathologic changes suggestive of CD. Gastroduodenal involvement often leads to symptoms similar to peptic ulcer disease or non-ulcer dyspepsia, such as epigastric pain and anorexia and sometimes signs of gastric outlet obstruction. Compared with distal CD, abdominal pain, cramping, and general malaise are more frequent with proximal disease.
There are a range of endoscopic findings reported in association with gastroduodenal CD. Danzi et al. [10] described patchy erythema, mucosal nodularity, aphthous lesion (Fig. 7.2a), ulceration, cobblestoning, and strictures (Fig. 7.2b, c) in their series of 14 patients. A bamboo-joint-like (BJL) appearance is an endoscopic finding characterized by swollen longitudinal folds transversed by erosive fissures or linear furrows, which seems to be associated with CD (Fig. 7.2d, e) [11, 12].
Fig. 7.2
Endoscopic findings of gastroduodenal Crohn’s disease. (a) Multiple aphthous lesions in the antrum. (b) Pyloric stricture associated with gastroduodenal Crohn’s disease. A patient presented with vomiting, epigastric pain, and weight loss. (c) Gastroduodenal disease tends to be contiguous. (d) Bamboo-joint-like appearance on the cardia. (e) Swollen longitudinal folds transversed by linear furrows (after indigo carmine spray)
The ulcerations in gastroduodenal CD were much more likely to be serpiginous or longitudinal (Fig. 7.3a, b) than round or oval. The round or oval ulcerations are felt to be suggestive of acid peptic disease. Gastroduodenal disease tends to be contiguous. In the series reported by Nugent and Roy [2], 60 % of patients had contiguous involvement of the antrum and duodenum. Forty percent had duodenal involvement only. Gastric CD usually involves the antrum. In isolated duodenal disease, any part of the duodenum can be involved, but the second part is most frequently affected, with typical mucosal defects on top of Kerckring’s folds (Fig. 7.3c, d), called “notching.” In the duodenum, stricturing may also occur. Upper endoscopy may lend itself to potential therapeutic intervention in patients with gastroduodenal CD. In case of stricturing with obstructive symptoms, there have been some reports on the successful balloon dilatation of strictures (Fig. 7.3e–g) [13].
