Distal esophageal involvement in Crohn disease: short treatment with adalimumab

The proximal gastrointestinal tract is involved in Crohn disease in less than 4 % of cases [1]. Esophageal involvement occurs in between 0.3 % and 2 % of the total patient population [2]. Upper gastrointestinal involvement is symptomatic or, more rarely, can be asymptomatic, as described by Souza et al. [3].

We report the case of a 49-year-old Italian man who presented with epigastric pain, poor appetite, weight loss, abdominal pain, and diarrhoea. He had already undergone a colonoscopy with retrograde ileoscopy with biopsies, which led to the diagnosis of Crohn disease. Laboratory tests confirmed the active phase of the disease (erythrocyte sedimentation rate 40 mm/hour, C-reactive protein 27 mg/L). Esophagogastroduodenoscopy (EGDS) performed 1 month after the patient’s proximal symptoms were first treated with a proton pump inhibitor showed a lesion with a diameter of about 18 mm at the distal third of the esophageal mucosa ([Fig. 1]).

Fig. 1 Pre-treatment esophagogastroduodenoscopy showing the area of ulceration in the distal esophagus.

Histological examination of multiple biopsies showed features compatible with Crohn disease. The patient subsequently underwent pretreatment screening for biological drugs and was given a first injection of adalimumab (Humira) at a dose of 160 mg subcutaneously. A second injection (80 mg subcutaneously) was given 15 days later, with subsequent rapid improvement in his proximal symptoms as well as the symptoms related to the ileocecal location. At 3 months after his initial presentation, follow-up EGDS showed a hyperemic mucus lining with healing of the ulcer over a wide area in the distal third of the esophagus ([Fig. 2]).

Fig. 2 Post-treatment esophagogastroduodenoscopy showing the healing ulcer.

Currently the patient’s disease is in remission.

Competing interests: None

Endoscopy_UCTN_Code_CCL_1AB_2AC_3AZ

References

• 1 Mottet C, Juillerat P, Pittet V. et al . Upper gastrointestinal Crohn’s disease.  Digestion. 2007;  76 Suppl 2 136-140
• 2 Lou G-C, Yang J M, Huang W. et al . Esophageal Crohn’s disease.  Endoscopy. 2009;  41 E257
• 3 Souza J LS, da Silva J G, Sipahi A M. Crohn’s disease of the esophagus without inflammatory activity confirmed by the use of endoscopy with narrow-band imaging.  Endoscopy. 2009;  41 E188