Boerhaave-mimicking esophageal perforation with subsequent esophagobronchial fistula formation as the primary manifestation of Crohn's disease

Crohn’s disease of esophagus, stomach and duodenum

Crohn’s disease with involvement of the esophagus, stomach and duodenum has a prevalence of 0.5% to 4% in symptomatic adult patients, but some studies have shown that these results may be underestimated, since upper gastrointestinal endoscopy is not performed routinely in the initial evaluation of the disease in adult patients, as it is in the pediatric population. In general, involvement of the upper gastrointestinal tract in Crohn’s disease occurs concomitantly with involvement of the lower gastrointestinal tract. The diagnosis depends on clinical, endoscopic, histological and radiological evaluation. The presence of aphthoid ulcers, longitudinal ulcers, bamboo-joint-like appearance, stenoses and fistulas are endoscopic findings suggestive of the disease, and it is important to exclude the presence of Helicobacter pylori infection. The primary histological findings, which facilitate the diagnosis, are the presence of a chronic inflammatory process with a predominance of lymphoplasmacytic cells and active focal gastritis. The presence of epithelioid granuloma, although less frequent, is highly suggestive of the disease in the absence of chronic granulomatous disease. Treatment should include the use of proton pump inhibitors associated with corticosteroids, immunomodulators and biological therapy according to the severity of the disease.

Internal fistula leakage due to a road traffic accident: a fortuitous diagnosis of Crohn's disease

BACKGROUND AND AIM

Fistulae are one of the most frequent complications of Crohn's disease (CD) and occur in 30-40% of patients. Conversely, free perforation is a rare complication and is one of the indications for emergency surgery of CD because of secondary peritonitis. We report a case of a spontaneous fistula rupture secondary to a road traffic accident.

METHODS

Case report.

RESULTS

A 22 year-old man, with no personal significant medical history, was admitted in the emergency room after a road traffic accident. He underwent abdominal CT, which revealed pelvis fractures, abnormal bowel wall of the terminal ileum (wall thickening and mucosal enhancement), peritoneal effusion within the pelvis, mesenteric nodes and extra-luminal gas within an area of mesenteric inflammation: these features were suggestive of ileum perforation associated with inflammatory bowel disease, most likely CD. Laparoscopic assessment was decided and an ileocaecal resection with ileocolonic anastomosis was performed. Histological analysis revealed terminal ileitis with ulcers, non caseating granulomas and submucosal fibrosis, a transparietal fistula and a caecoappendicular inflammation, confirming CD. Post surgical outcome was uneventful and the patient was discharged at day 9.

CONCLUSION

Our patient presented this rare complication revealing CD. The involvement of the terminal ileum and fistulae were characteristics of CD. Rupture of the fistula was favored by the trauma and responsible for the peritonitis. A resection with primary anastomosis was possible. To our knowledge, it is the first case described for the rupture of an ileal fistula secondary to traumatism in a patient with CD.

Transabdominal Approach for Management of Boerhaave's Syndrome

Several transthoracic approaches have been described for the surgical management of Boerhaave's syndrome that carry their own morbidity in patients who can be systemically unwell at presentation, and best practice is not established. We introduce a novel transabdominal approach to manage the perforation and spare these patients the trauma of a thoracotomy. Four patients with spontaneous esophageal rupture were managed using a transabdominal approach. Postoperative complications, length of intensive care unit stay, postoperative hospital stay, time to oral intake, and morbidity and mortality were used as outcome measures. After operation, the median intensive care unit stay was 4 days (range, 0–5) in patients who required a median of 10.5 days (range, 6–17) to establish oral intake. One patient required a transthoracic drainage of an empyema and one patient required percutaneous drainage of a mediastinal collection. The median length of stay was 38 days and there was zero mortality. The transabdominal approach is safe and effective for the management of Boerhaave's syndrome and should be considered in the treatment paradigm for this condition. Intrathoracic complications account for postoperative morbidity.

Heartburn and multiple-site foregut perforations as primary manifestation of Crohn's disease

Crohn's disease may affect any segment of the digestive tract, more commonly the distal ileum, colon and/or perianal region. There is an increasing number of reports dealing with foregut Crohn's disease. We present the case of a patient with a history of heartburn and multiple spontaneous perforations of the esophagus, duodenum and jejunum as a primary manifestation of Crohn's disease who required emergency surgical and endoscopic procedures. Early detection of Crohn's disease may decrease the incidence of acute life-threatening complications provided that appropriate medical treatment is administered and a multidisciplinary approach is offered to these patients.

Dysphagia in Crohn's disease: a diagnostic challenge

Dysphagia is a rare manifestation in a patient with Crohn's disease. We report on the case of a patient with long-standing Crohn's disease who developed progressive dysphagia over 3 years. Endoscopy showed minimal distal oesophagitis with non-specific histological findings. Further investigation with cinematography, barium swallow and manometry established an achalasia-like motility disorder. Biopsies obtained from the oesophagus were non-specific. Balloon dilatation was performed. Initial success was followed by recurrent dysphagia. At repeat endoscopy, an oesophageal fistula was detected. An attempt at conservative medical management failed and oesophagectomy was successfully performed. Pathology results of the resected specimen confirmed the suspected diagnosis of oesophageal Crohn's disease. Even if achalasia is suspected in a Crohn's patient, it should be taken into consideration that the motility disorder could be the result of a transmural inflammation with or without fibrosis caused by Crohn's disease.