Endoscopic radial incision combined with dexamethasone therapy for stricture of the esophagus caused by Crohn’s disease

A 35-year-old man who had experienced substernal pain for 3 years and dysphagia for 6 months was admitted to our hospital. Laboratory data were negative for the autoantibodies and T-SPOT.TB test. A chest computed tomography scan showed thickening of the esophageal wall. Colonoscopy indicated multiple ulcers in the terminal ileum and ileocecal valve ([Fig. 1]). Pathology indicated moderate active chronic colitis with erosion and crypt abscess ([Fig. 2]). Gastroscopy demonstrated scarring changes and severely ulcerated lesions of the esophagus ([Fig. 3]). The pathology revealed only granulation tissue ([Fig. 4]). The esophageal ulcers were longitudinal with annular stenosis. Ultrasonic gastroscopy indicated that the lesions involved the submucosa and muscular layer. Therefore, the patient was diagnosed as having Crohn’s disease (esophagus involved, stenosis type, active, moderate).

Fig. 1 Multiple ulcers in the terminal ileum and ileocecal valve.

Fig. 2 Moderate active chronic colitis with erosion and crypt abscess (hematoxylin and eosin × 20).

Fig. 3 Longitudinal ulcers and stricture of the esophagus.

Fig. 4 The pathology of the esophagus indicated granulation tissue (hematoxylin and eosin × 20).

Considering the risk factors of this patient, infliximab was used to induce remission, with initial success in controlling the substernal pain and dysphagia. However, 6 months later, the dysphagia recurred more severely, and gastroscopy showed a severe cicatricial stricture (diameter 0.2 cm) of the esophagus, 24 – 25 cm from the incisors. Thus, endoscopic radial incision was performed and the symptoms improved (diameter 0.7 cm) ([Video 1]). However, the stricture recurred after 2 weeks. Endoscopic incision with submucosal injection of dexamethasone (5 mg) was used repeatedly every 2 weeks to relieve the stricture; in total five injections were administered. The infliximab treatment was also continued during the period.

Video 1 Endoscopic incision in a patient with esophageal stricture caused by Crohn’s disease.

Currently, the patient’s condition remains stable. A recent gastroscopy indicated a slight esophageal stenosis (diameter 0.9 cm) but the ulcer had disappeared ([Fig. 5]).

Fig. 5 A recent gastroscopy indicated a slight esophageal stenosis (diameter 0.9 cm).

The incidence of esophageal Crohn’s disease is about 0.3 % – 2 % [1]. Stricture and obstruction of the esophagus are common complications. This is a rare case and to date, the condition of this patient remains stable. Thus, we suggest that endoscopic incision combined with local glucocorticoid injection therapy is an alternative to surgery for patients with esophageal stricture caused by Crohn’s disease.

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• Reference

• 1 Lou GC, Yang JM, Huang W. et al. Esophageal Crohn’s disease. Endoscopy 2009; 41 (Suppl. 02) E257