Pyloric stenosis as a manifestation of isolated gastric Crohn’s disease responding to intralesional steroid injection and balloon dilation: a case report

BACKGROUND: Crohn’s disease is a chronic inflammatory condition that can affect the gut from mouth to anus. Gastroduodenal involvement is seen in less than 5% of all patients with Crohn’s disease. Among those cases, isolated gastric Crohn’s disease is even rarer. Although most patients with isolated gastric involvement have nonspecific complaints, very few of them do develop features of pyloric obstruction. There is a paucity of data on specific management of gastric Crohn’s disease owing to its rarity and its frequent coexistence with colonic or ileal disease. We report a case of a patient who had pyloric stenosis as a manifestation of isolated gastric Crohn’s disease responding to intralesional steroid injection and balloon dilation. CASE PRESENTATION: A previously healthy woman presented with recurrent postprandial vomiting, epigastric discomfort, and unintentional weight loss over 6 months. She had no diarrhea or extraintestinal manifestations. Clinically, she was pale and dehydrated. Examination of systems was unremarkable except for mild epigastric tenderness. Her initial laboratory findings were normocytic normochromic anemia, high inflammatory markers, and hypokalemia. Esophagogastroduodenoscopy revealed an inflamed pyloric mucosa with features of pyloric obstruction. Furthermore, magnetic resonance enterography confirmed the pyloric stenosis. Histopathological examination of a biopsy from the pylorus revealed noncaseating granuloma with superficial ulceration. Tuberculosis and sarcoidosis were excluded by appropriate investigations, and a diagnosis of gastric Crohn’s disease was made. Following the initial resuscitation, intralesional steroid injection and controlled radial expansion balloon dilation of the pylorus were carried out. The patient was commenced on azathioprine as a maintenance treatment, which led to a successful dilation and remarkable symptom improvement. CONCLUSION: Symptoms of pyloric obstruction as a manifestation of isolated gastric Crohn’s disease are extremely unusual in clinical practice, awareness of which would facilitate early appropriate investigations and treatment.