GRANULOMATOUS (CROHNS) DISEASE OF THE UPPER GASTROINTESTINAL-TRACT - A STUDY OF 22 PATIENTS WITH MUCOSAL GRANULOMAS

Gastroduodenal abnormalities may occur in patients with Crohn's disease and are usually associated with ileal or colonic involvement. This study examined clinical features of 22 patients with Crohn's disease involving the upper gastrointestinal tract seen at the University of British Columbia Hospital, Vancouver, British Columbia, from 1980-90. In all patients, the diagnosis was defined by the specific histological feature of mucosal granulomatous inflammation in the upper gastrointestinal tract, while other causes (such as sarcoidosis, tuberculosis and bacterial gut pathogens) were excluded. Patients with Crohn's disease and another gastroduodenal disorder (eg, peptic ulcer, erosions, gastritis, duodenitis) were excluded if granulomas were not detected. There were 10 males and 12 females, aged 15 to 57 years, at the time of detection of upper gastrointestinal tract granulomatous disease. In seven patients, disease was localized to the upper gastrointestinal tract: one, granulomatous oropharyngeal disease alone; five, granulomatous gastritis alone; one, granulomatous duodenitis alone. In three patients, granulomatous inflammatory disease was concurrently diagnosed in the upper and lower gastrointestinal tracts. In the remaining 11 patients, granulomatous disease in the upper gastrointestinal tract was detected after Crohn's disease was initially detected om the distal gastrointestinal tract: five, granulomatous gastritis alone; four, granulomatous duodenitis alone; two, both granulomatous gastritis and duodenitis. In one final patient, granulomatous oropharyngeal disease was detected in a buccal mucosal biopsy one year prior to diagnosis of Crohn's disease in the lower gastrointestinal tract. Upper abdominal pain was the most common symptom (over 90% of patients). Weight loss (over 50%), nausea and vomiting (over 30%) were also common and, occasionally, upper gastrointestinal tract bleeding (two patients) occurred. Endoscopic features included mucosal erosions, thickening of mucosal folds, ulceration, granularity, nodularity and cobblestoning. The most common radiographic change was mucosal thickening, but the barium studies were most often normal. Patients have been followed for a mean of five years (1.5 to 11 years). One patient required surgical intervention to treat a duodeno-ileocolic fistula but this patient had a prior partial ileocolic resection and the fistula involved the intestinal anastomosis the other 21 patients were treated with pharmacological agents for Crohn's disease as well as added medications including ranitidine in six patients, omeprazole in four, sulcralfate in one, and a combination of ranitidine and sucralfate in two. In conclusion, 22 patients with granulomatous mucosal inflammatory disease in the upper gastrointestinal tract typical of Crohn's disease were seen. A benign clinical course was observed, possibly reflecting an early pathological phase in the disease process. Extended long term follow-up of these patients might further delineate factors that could accurately define prognosis and determine the requirement for surgical treatment.