Crohns disease

Although Crohn's disease (CD) most commonly affects the terminal ileum and/or the colon, involvement of the upper gastrointestinal tract is frequently found in both adults and children. Symptoms such as epigastric pain, early satiety, nausea, vomiting, weight loss and, less frequently, hematemesis and melena are commonly reported in these patients and have previously been related to reflex inhibition of foregut motility secondary to inflammation and partial obstruction of the distal small bowel. It has been shown that macroscopic and/or histological abnormalities are found in up to 70% of adults and 90% of children with CD.45 Endoscopic findings include patchy or streaky mucosal reddening, edema, single or multiple nodularities, a cobblestone appearance, rigidity of the antrum wall, narrowing of the lumen, aphthoid erosions and linear or serpiginous ulcers (Figure 7.2). Histological diagnosis of gastric CD is best achieved by the detection of epithelioid granulomas and giant cells in biopsy specimens, although focal, non-specific gastritis containing a mixed inflammatory cell infiltrate is observed in a high percentage of patients. Endoscopic and/or histo-logical gastric involvement in CD may be present in the absence of upper gastrointestinal symptoms and may precede diagnostic findings in the small and large bowel. The prevalence of granulomas in bioptic specimens of adult patients is highly variable, ranging from 7 to 83%, whereas in children it is up to 40%.46 Table 7.3 lists the most common causes of granulomatous gastritis in children. In

Crohn Disease Children
Figure 7.2 Small pre-pyloric ulcers (arrows) in a 14-year-old girl with Crohn's disease.

Table 7.3 Causes of granulomatous gastritis in children

Systemic disease Crohn's disease

Chronic granulomatous disease

Sarcoidosis

Other vasculitides

Infectious causes

Tuberculosis

Helicobacter pylori

Histoplasmosis

Syphilis

Parasites

Isolated Idiopathic Foreign substances recent years a characteristic pattern of inflammation, the so-called focal enhanced gastritis, has caused great interest, because of the observation that it is quite common and is certainly seen with greater frequency than granulomas in both adults and children. It is found more commonly in the antrum than in the body and is characterized by at least one foveola/gland or small groups of foveo-lae/glands surrounded by infiltrated inflammatory cells that consist mainly of lymphocytes, mono-cytes and occasionally neutrophils, resembling focal inflammation observed in the intestinal and colonic mucosa of patients with CD.

In adults, two prospective studies have evaluated the prevalence of focal enhanced gastritis in patients with CD compared with a control population. Histological focally enhanced gastritis was observed in more than half of CD patients, suggesting that it could be a diagnostic marker of the disease.47,48 However, in both studies no patients with ulcerative colitis were included. Subsequently, Parente et al found, in an adult population, focally enhanced gastritis in 43% of H. pylori-negative CD patients, 12% of ulcerative colitis

(UC) patients and 19% of controls with no inflammatory bowel disease (IBD). The authors reported a specificity and positive predictive value of focally enhanced gastritis for CD of 84% and 71%, respectively.49 These results have been confirmed in two pediatric studies. Sharif et al showed that focally enhanced gastritis was present in 65.1% of children with CD, 20.8% of children with UC and 2.6% of children without IBD.50 More recently, Kundhal et al found focally enhanced gastritis in 52% of children with CD and 8% of patients with UC.51 This suggested that, although this histologi-cal finding was highly suggestive of CD, it could not be seen as a specific diagnostic marker.

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