Stenosis of the proximal intestine in Crohn's disease – a case report

A 34 year old male patient was referred to our department with heartburn, progressive sickness, vomiting, intermittent upper abdominal pain, feeling of early saturation and weight loss of 10kg within 4 months. An ultrasound scan 4 weeks before had been considered normal and a gastroscopy had revealed signs of gastritis with no effect of a proton pump inhibitor therapy. The ultrasound scan focussed on the upper GI-tract. There was a far stretching stenosis of the proximal jejunum with widening of the mucosal layer, multiple paraintestinal lymph nodes and an accelerated flow of the mesenteric superior artery. These findings were confirmed by CT-Scan. The following endoscopy revealed fissural ulcerations starting in the duodenum and prominent stenosis of the proximal jejunum. Histological examination showed an active inflammation of the mucosa without demonstration of granuloma. A coloscopy was normal. Parenteral steroid treatment was started with improvement of symptoms within 3 days and was continued with cortisone and azathioprin orally. On follow-up ultrasound scans the stenosis and mucosal widening in the proximal jejunum were regressing. In summary we present a rare case of Crohn's disease onset with isolated involvement of the proximal jejunum in an adult patient. Symptoms are mostly due to proximal GI-tract stenosis, while fistulas do not develop frequently and diarrhoea does not occur. First choice treatment is a conservative approach with steroids and azathioprin in the longterm. The ultrasound scan guided the way to the correct diagnosis in this case and was useful for follow-up examinations.