PC1181: Isolated Upper Gastrointestinal Findings in Pediatric Patient Found to Have Crohn's Disease

Introduction: Crohn’s disease (CD) is a type of inflammatory bowel disease (IBD) defined by transmural intestinal inflammation that can affect the entire digestive tract. CD is described by location and phenotype, with less than 10% having isolated perianal involvement, upper gastrointestinal or extraintestinal manifestations. Because of CD’s diverse presentations, it can become difficult to diagnose CD immediately without evaluating other GI pathology. Furthermore, pediatric presentations of CD are often complicated by impaired growth and development. For pediatric gastroenterologists, it becomes crucial to weigh the risks and benefits of subjecting patients to potentially life-long medical treatments alongside their clinical suspicion for IBD. Here, we report a case of duodenal stricturing and gastro-duodenitis in the presence of duodenal ulcers associated with CD in a pediatric patient.

Case Description: A 9-year-old previously healthy boy presented to the hospital with one week of vomiting and diarrhea. Initially sent home for suspected acute-gastrointestinal-enteritis, he returned within a few days for worsening emesis and abdominal pain. Abdominal ultrasound was unremarkable; CT abdomen showed gastro-duodenitis. Initial Esophagogastroduodenoscopy (EGD) showed gastric outlet inflammation secondary to duodenal ulcers with histopathology significant for acute inflammation and reactive changes. Patient was started on acid suppression and antibiotics until H. Pylori results were negative. Given no improvement in symptoms and worsening inflammatory markers, decision was made to re-scope. Subsequent endoscopy demonstrated worsening of duodenal ulcerations with exudate, raising suspicion for CD, Zollinger-Ellison Syndrome, or infection. Biopsies from repeat endoscopy again showed acute inflammation without visualization of granulomas or crypt abscesses. An Upper-GI-with-small-bowel follow-through (UGI-SBF) was attempted, however the patient did not tolerate oral contrast. Magnetic-resonance-enterorrhaphy suggested duodenitis with luminal narrowing in the transverse duodenum, however the study was suboptimal due to motion artifact. Reattempt UGI-SBF with nasogastric tube confirmed transverse duodenal narrowing, but no other small-bowel activity. Although strongly suspicious for CD, we had no definitive evidence with pending stool studies. Given potential evidence of IBD on imaging and worsening pain, we started empiric corticosteroids. One day later, the Prometheus-IBD panel was strongly suggestive of CD and fecal-calprotectin level was over 3,000mcg/gm. The patient demonstrated excellent response with decreased pain and tolerance of oral diet.

Discussion: Our patient portrays the difficulty of diagnosing pediatric IBD, specifically CD. He presented with acute gastrointestinal symptoms that originally seemed infectious in etiology. Not until multiple weeks of weight loss, worsening abdominal pain and poor lab values, all clinical indicators of IBD, was CD revisited. As mentioned earlier, few patients present with isolated upper GI findings in CD, and likely even fewer with such acute symptoms.

Conclusion: We demonstrate common challenges to diagnosing pediatric illnesses, how they delay the diagnosis in atypical CD presentations, and the importance of using clinical progression to dictate treatment when expedient testing is not available.