S4921 Strictures, Fistulas, and Diverticula, Oh My! A Case of Complicated Esophageal Crohn’s in an Adult Patient

Introduction: Esophageal involvement is a rare manifestation of Crohn’s Disease (CD). Prevalence among patients with CD ranges from 3.3% to 6.8%. It is more commonly seen in children, is rarely isolated, and coincides with oral, ileal, or colonic disease. Endoscopic findings may include stricture, fistula, punched-out lesions, or pseudo-polyps. Non-caseating granulomas are seen in ∼25% of cases, making diagnosis challenging. Treatment includes acid suppression, nutrition supplementation, immunosuppression, mechanical dilation, and rarely esophagectomy. We present a patient with longstanding, untreated CD found to have suspected severe esophageal CD. Case Description/Methods: A 47-year-old non-smoker male with CD diagnosed at 8 years old presented with dysphagia, diarrhea, weight loss, and pyoderma gangrenosum. He had no prior surgery and had been off adalimumab for 4 years. Notable labs include normal C-reactive protein (3.2), low albumin (3.2), thrombocytosis (plt 427), mildly elevated fecal calprotectin (86). Endoscopy showed oral ulcers and both proximal and distal esophageal strictures requiring ultra-slim upper endoscope for traversal. There was associated up-stream dilation, mid-esophageal diverticula, and diffuse white plaques. Colonoscopy revealed erythematous, friable distal ileum, deformed mildly stenotic ileocecal valve with surrounding fistulous opening. His colon otherwise appeared healthy. Pathology revealed mildly active esophagitis with reactive epithelial changes and candida esophagitis. He had mildly active ileitis and focally active colitis in the right colon. Subsequent esophagram showed complex strictures, a blind-ending sinus tract, diffuse intrathoracic esophageal wall irregularity, numerous pseudodiverticula, mucosal ulcerations, and abnormally delayed clearance of contrast from the esophagus. Savory dilation under fluoroscopy was successful. A naso-jejunal tube was placed for nutrition. He was started on ustekinumab. Discussion: Our patient had suspected severe, chronically active, proximal esophageal CD with comparatively mild ileocolonic disease- an atypical presentation of a rare disease manifestation. While no granulomas were found, there was no clinical history or endoscopic findings to suggest other causes of stricture, weight loss, or malnutrition. Thus, one should maintain a high index of suspicion for esophageal involvement when performing diagnostic upper endoscopy in CD to initiate prompt nutritional support, careful planning of dilation to minimize perforation risk, & biologic therapy.