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Wewer, V.1; Paerregaard, A.1; Faerk, J.2; Matzen, P.3
1Dept. of Pediatrics, Hvidovre Hospital, Hvidovre, 2Dept. of Pediatrics, Holbaek Hospital, Holbaek, 3Dept. of Gastroenterology, Hvidovre Hospital, Hvidovre, Denmark
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Introduction: Duodenal strictures associated with Crohn’s disease (CD) may cause severe morbidity. In adult patients with obstructive symptoms endoscopic dilation with hydrostatic balloons is a therapeutic option to avoid intestinal surgery. Reports of this treatment in children and adolescents are few.
Methods: A 16 years old girl was admitted with weight loss of 4 kg, nausea, epigastric pain and explosive vomiting during three months. Diagnostic work-up revealed elevated serum levels of CRP, orosomucoid, leucocytes and pancreatic fraction of amylase, a positive ASCA and low albumin. Upper GI endoscopy disclosed a normal stomach, pylorus and duodenal bulb, but a severe prestenotic dilation in the 2nd part of duodenum due to a stricture at the level of the papilla of Vater. Duodenal biopsies revealed acute and chronic inflammation. Coloileoscopy showed inflammation of terminal ileum. Biopsies from ileum, colon ascendens, transversum and descendens showed inflammation with granulomas. MRCP was normal. After failed medical therapy another upper GI endoscopy was performed to evaluate the possibility of endoscopic dilatation. Two 8–9 mm strictures were seen in 2nd part of duodenum together with Crohn’s ulcerations. The papilla of Vater could not be seen.
Results: Treatment: Corticosteroids were given together with elemental nutrition in a four-weeks period with considerable symptomatic relief. However, symptoms relapsed after a few weeks. During the first year of disease several corticosteroid courses were needed without induction of remission, and azathioprine was given. MRCP then revealed a slightly dilated ductus choledochus a normal ductus pancreaticus terminating in the stenotic duodenum.
Within 6 months a series of five endoscopic dilations with Rigiflex balloons was performed (video illustrated). Corticosteroids were injected in the stricture at the 4rd dilatation. A lumen of 20 mm was achieved. The patient had symptomatic relief, a weight gain of 1.2 kg during the six months period of dilatation and corticosteroids were discontinued.
Conclusion: Relief of symptoms and weight gain were established by repeated balloon dilation of the duodenal strictures.
© 2004 Lippincott Williams & Wilkins, Inc.
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