[Gastroduodenal involvement and circumscribed intestinal stricture in Crohn disease]

Abstract

Symptomatic gastroduodenal Crohn's disease (CD) is rare although new endoscopic/histologic data indicate a typical focally enhanced gastritis in up to half of all patients with CD. One third of the patients with symptomatic gastroduodenal CD undergo surgery, most of them for (gastro-) duodenal obstruction. Gastroenterostomy with vagotomy is the surgical treatment of choice. Resection, strictureplasty or balloon dilatation can be performed in selected patients. Enterogastric and enteroduodenal fistulas are rare, frequently missed during routine examination and often detected only during laparotomy. Treatment of those fistulas consists of resection of distal bowel (fistula origin) with suture closure of the fistula opening in the stomach/duodenum. Recurrence rate after surgery for gastroduodenal CD is lower than in ileal and/or colonic disease, and only a minority of the patients requires further surgical intervention. Bowel obstruction is a frequent indication for surgery in CD. Interventional or surgical therapy should be performed in chronic-recurrent obstruction, progressive stenosis and stenosis refractory to medical treatment. In short fibrous stenosis of the small bowel or ileocecal anastomosis without acute inflammation or perforating complications balloon dilatation or, if endoscopic access is not possible, strictureplasty should be performed. In all other cases, especially in colonic strictures with their increased risk of malignancy, resection is the treatment of choice. The results of balloon dilatation, strictureplasty or resection are comparable with five year reoperation rates reported between 20% and 38%.