The Gates of Hell: Crohn’s Disease Isolated to the Pylorus and Ileo-Cecal Valve

Excerpt

In 2006, a 24-year-old male of African-Caribbean ancestry was first evaluated with a 2-year history of low-grade fever, weight loss, decreased appetite, abdominal bloating and occasional, self-limited rectal bleeding. Moreover, he reported intermittent diffuse abdominal pain occurring before meals, relieved by eating, and at times awakening him at night. He was noted to have some mild epigastric and right lower quadrant tenderness and normal bowel sounds. An upper gastrointestinal series was reported as showing pyloric narrowing, an ulcerated duodenal bulb (Fig. 1a), and narrowing at the ileo-cecal junction without obstruction (Fig. 1b). An endoscopy confirmed the presence of severe pyloric stenosis without associated H. pylori gastritis; colonoscopy revealed ulceration of the ileo-cecal valve but otherwise normal colonic mucosa. Granulomata were not observed in pathologic specimens of pylorus and ileo-cecal valve. His past history was only significant for a positive tuberculin test in 1999 for which he had been treated with isoniazid. A secretin stimulation test performed in order to evaluate for the presence of a neuroendocrine tumor was negative. Serum antibodies associated with the presence of inflammatory bowel disease were not detected. He was diagnosed with Crohn’s disease based on these findings; treatment with rabeprazole 20 mg daily and azathioprine 100 mg daily transiently improved his symptoms.

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