Esophageal manifestation of Crohn's disease

Objectives: Crohn's disease (CD) is a lifelong disease that may affect any part of the gastrointestinal tract. Its esophageal manifestation, though rare, may be seen as the first sign of this disease.

Methods: Patients with esophageal CD evaluated between 2004 and 2009 were surveyed.

Results: Three cases were diagnosed, each with a different clinical picture. The first case was an 18-year-old woman, who presented with dysphagia, odynophagia and a 2kg weight loss. She had oral aphthae and a small perianal fistula. Upper gastrointestinal endoscopy (UGE) revealed punchhole-pattern ulcers in the esophagus. The stomach and the duodenum were normal. Histological examination indicated acute ulcerative oesophagitis without noncaseating granuloma. Both the cytomegalo-and herpes simplex virus polymerase chain reaction were negative. Colonoscopy and histological examination led to a diagnosis of advanced ileal and colonic CD.

The second case was a 28-year-old female, who presented with reflux symptoms. Deep ulcers with bridging signs were seen in the esophagus on UGE. There was no other manifestation in the gastrointestinal tract. Nearly complete healing was achieved with through courses of steroid and immunosuppressant therapy and rabeprazole. The third patient was a 77-year-old female with fever and epigastric and retrosternal pain. Deep ulcerations were seen in the esophagus, and small ulcerations in the stomach and duodenum. Ileocolonoscopy revealed only diverticulosis of the sigmoid colon.

Conclusions: Esophageal CD may present with the symptoms of reflux disease. The spectrum of esophageal CD may vary from mild esophagitis with small erosions to transmural involvement with perforation and fistulization to adjacent organs. The endoscopic manifestations of esophageal CD may include vertical lines in the esophageal mucosa, aphthous ulcers, deep ulcers, erythematous nodules and polypoid lesions, pseudomembrane formations, strictures and formations of multiple mucosal bridges. An esophageal manifestation may be the first and the only sign of CD. The histological diagnosis of esophageal CD is challenging and the diagnosis may be missed.