Regístrese
¿Aún no está registrado?
Información relevante

Consulte los artículos y contenidos publicados en éste medio, además de los e-sumarios de las revistas científicas en el mismo momento de publicación

Máxima actualización

Esté informado en todo momento gracias a las alertas y novedades

Promociones exclusivas

Acceda a promociones exclusivas en suscripciones, lanzamientos y cursos acreditados

Crear Mi cuenta
Buscar en
GE - Portuguese Journal of Gastroenterology
Toda la web
Inicio GE - Portuguese Journal of Gastroenterology Ulcerous Esophagitis in a Young Immunocompetent Patient
Journal Information
Vol. 23. Num. 6.November - December 2016
Pages 285-336
Share
Share
Download PDF
More article options
Visits
2017
Vol. 23. Num. 6.November - December 2016
Pages 285-336
Endoscopic Snapshot
DOI: 10.1016/j.jpge.2016.02.004
Open Access
Ulcerous Esophagitis in a Young Immunocompetent Patient
Esofagite Ulcerosa numa Doente Jovem e Imunocompetente
Visits
2017
Lídia Roque Ramosa,
Corresponding author
lidia.roque.ramos@gmail.com

Corresponding author.
, Rita Barosaa, Pedro C. Figueiredoa, Tânia Meiraa, Helder Oliveirab, João Freitasa
a Gastroenterology Department, Hospital Garcia de Orta, Almada, Portugal
b Pathology Department, Hospital Garcia de Orta, Almada, Portugal
This item has received
2017
Visits

Under a Creative Commons license
Article information
Full Text
Bibliography
Download PDF
Statistics
Figures (3)
Show moreShow less
Full Text

A 26-year-old overweight female patient presented to the emergency department with severe odynophagia for six days and retrosternal pain in the past two weeks. She had a history of appendectomy and a recent diagnosis of irritable bowel syndrome (IBS). The patient denied regular medication or recent use of any drugs, namely antibiotics or non-steroidal anti-inflammatory drugs. Laboratory studies showed an increased C-reactive protein and a negative HIV serology. An esophagogastroduodenoscopy (EGD) revealed several ulcers in the lower third of the esophagus, the largest with 15mm and raised borders (Fig. 1). Biopsies were taken from the edges and bottom of the ulcer. The patient was admitted and empirically started on proton pump inhibitor (PPI) and acyclovir. Serologies ruled out HSV 1 and 2, CMV, EBV and VZV recent infections and syphilis. Histological examination showed an intense chronic inflammatory infiltrate involving the mucosal, submucosal and muscular layers (Fig. 2a) and an epithelioid granuloma with a giant cell (Fig. 2b). There were no viral cytopathic effects or acid-fast bacilli. Hence, our patient had a non-caseous esophageal granulatomatosis. We excluded tuberculosis, sarcoidosis and granulomatosis with polyangiits (Wegener's granulomatosis) based on a negative Mantoux and IGRA tests and normal chest X-ray, angiotensin conversion enzyme levels, serum electrophoresis and renal function. At this point, we considered the hypothesis of Crohn's disease and given the patient's complaints of intermittent diarrhea and abdominal discomfort, labeled as IBS, an ileocolonoscopy was performed. Several areas of erythema with aphthous erosions, and ulcers, stellar and circular, the largest with 10mm, were found in the colon and rectum (Fig. 3); and a posterior commissure anal fissure was also identified. Biopsies showed architectural gland distortion, goblet cell depletion, cryptitis and submucosal lymphoplasmacytic infiltrate, findings consistent with Crohn's disease. The PPI was maintained and the patient was started on swallowed fluticasone (500mcg two times a day) with significant improvement of the proximal symptoms. In turn, a decision was made to start azathioprine and infliximab, due to the patient's young age, upper gastrointestinal and colonic involvement and perianal disease. An EGD repeated six months after presentation showed complete esophageal mucosal healing.

Figure 1.
(0.08MB).

Esophagogastroduodenoscopy: lower third of the esophagus with a typical “punched-out” ulcer.

Figure 2.
(0.44MB).

Esophageal biopsies histological examination: (a) hematoxilin & eosin 40× – intense inflammatory infiltrate permeating the mucosal, submucosal and muscle layers. (b) Hematoxilin & eosin 200× – non-caseous epithelioid granulomas with a giant cell (arrow).

Figure 3.
(0.09MB).

Ileocolonoscopy: active colitis with two superficial ulcers and a deep stellate ulcer in the left colon.

Foregut Crohn's disease has an estimated incidence of 1–13% in patients with ileocolonic disease. Moreover, esophageal Crohn's disease lesions are reported in 15% of adults and 44% of pediatric patients with Crohn's disease, when an EGD is systematically performed, suggesting that this entity is probably underdiagnosed.1 In contrast, isolated esophageal Crohn's is extremely rare with very few reported cases.2 The diagnosis implies ruling out other causes of esophagitis, namely, reflux disease, medications, viral, fungal and mycobacterial infections, sarcoidosis, vasculitis and carcinoma.2 Endoscopic features are not specific and include erythema, erosions and ulcers, aphthous and superficial or deep punched-out, strictures and fistulas.2–4 As for other Crohn's disease locations, non-necrotizing granulomas are uncommonly seen (7–9% in esophageal biopsies)2 and a high index of suspicion is needed to consider this diagnosis in the absence of known extra-esophageal Crohn's disease. Therapeutic options include systemic corticosteroids, immunosupressants and anti-TNFα, the latter reserved for severe and refractory disease.2–5 PPIs have no proved efficacy in mucosal healing and are used for symptom relief. Finally, topical swallowed aerosolized corticosteroids were shown to induce esophageal healing in a recent case-report and the authors propose topical steroids as an effective adjuvant therapy.6

Ethical disclosuresProtection of human and animal subjects

The authors declare that no experiments were performed on humans or animals for this study.

Confidentiality of data

The authors declare that no patient data appear in this article.

Right to privacy and informed consent

The authors declare that no patient data appear in this article.

Conflicts of interest

The authors have no conflicts of interest to declare.

References
[1]
K.G. Davis
Crohn's disease of the foregut
Surg Clin North Am, 95 (2015), pp. 1183-1193 http://dx.doi.org/10.1016/j.suc.2015.07.004
[2]
J. Feagans,D. Victor,V. Joshi
Crohn disease of the esophagus: a review of the literature
South Med J, 101 (2008), pp. 927-930 http://dx.doi.org/10.1097/SMJ.0b013e31818047be
[3]
G. D’Haens,P. Rutgeerts,K. Geboes,G. Vantrappen
The natural history of esophageal Crohn's disease: three patterns of evolution
Gastrointest Endosc, 40 (1994), pp. 296-300
[4]
G.A. Decker,E.V. Loftus,T.M. Pasha,W.J. Tremaine,W.J. Sandborn
Crohn's disease of the esophagus: clinical features and outcomes
Inflamm Bowel Dis, 7 (2001), pp. 113-119
[5]
A. Dignass,G. Van Assche,J.O. Lindsay,M. Lémann,J. Söderholm,J.F. Colombel
The second European evidence-based Consensus on the diagnosis and management of Crohn's disease: current management
J Crohn's Colitis, 4 (2010), pp. 63-101
[6]
P. Zezos,G. Kouklakis,A. Oikonomou,M. Pitiakoudis,C. Simopoulos
Esophageal Crohn's disease treated “topically” with swallowed aerosolized budesonide
Case Rep Med, 2010 (2010), pp. 4-7
Copyright © 2016. Sociedade Portuguesa de Gastrenterologia
es en pt
Política de cookies Cookies policy Política de cookies
Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el análisis de sus hábitos de navegación. Si continua navegando, consideramos que acepta su uso. Puede cambiar la configuración u obtener más información aquí. To improve our services and products, we use "cookies" (own or third parties authorized) to show advertising related to client preferences through the analyses of navigation customer behavior. Continuing navigation will be considered as acceptance of this use. You can change the settings or obtain more information by clicking here. Utilizamos cookies próprios e de terceiros para melhorar nossos serviços e mostrar publicidade relacionada às suas preferências, analisando seus hábitos de navegação. Se continuar a navegar, consideramos que aceita o seu uso. Você pode alterar a configuração ou obter mais informações aqui.
es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos