The results of these studies have been controversial

The results of these studies have been controversial. described by Gottlieb and Alpert in 1937 [1C3]. Since then, DCD still remains a complex clinical entity with a controversial management of the disease. The most common site of duodenal Crohn’s disease is the duodenal bulb, and obstruction is the most frequent presentation [1, 4]. Medical management with antiinflammatory and antiacid Mouse monoclonal to FAK medications is effective in patients without obstruction. However, surgery has been reported to be necessary for as many as 91% of patients with obstruction [1, 5, APS-2-79 6]. Options for surgical management of complicated DCD include bypass, resection, or stricturoplasty. Resection has been abandoned because of associated increased morbidity; therefore, bypass procedures and stricturoplasty have become the accepted surgical options for DCD [5, 7C9]. Although Crohn’s disease can involve any segment of the gastrointestinal tract, isolated Crohn’s disease of duodenum without extraduodenal involvement is extremely rare. In this report, we described an isolated case of DCD and reviewed the surgical options. 2. Case A 33-year-old male patient was referred to our clinic with a 6-month history of intermittent, abdominal pain accompanied by progressive nausea, bilious emesis, and weight loss. His defecation habits were normal. On physical examinations, only a slight tenderness and fullness was noted in the epigastric region. Routine blood work revealed a mild normocytic anemia (Hgb:?12,0?g/dL, normal range:?13,5C17,2?g/dL). Biochemical parameters were unremarkable. He subsequently underwent an esophagogastroduodenoscopy (EGD), abdominal computerized tomography (CT), and colonoscopy. EGD revealed a tight stricture with mucosal edema and the longitudinal ulcerations in the duodenal bulb with a near-complete obstruction (Figure 1). The biopsy specimens of the duodenum showed severe inflammation, mixed chronic inflammatory infiltrate in lamina propria, and cryptitis with the evidence of DCD (Figures ?(Figures22 and ?and3).3). CT and colonoscopy were normal. Based on these clinical, radiological, and pathological findings, isolated DCD was diagnosed, and total parenteral nutrition therapy was initiated along with nasogastric decompression. After having the nutritional status of APS-2-79 the patient improved, he went on laparoscopic exploration. A stricture was found in the first part of the duodenum with a dilated stomach. A laparoscopic gastrojejunostomy was performed without vagotomy. The patient tolerated the procedure well and was discharged without any adverse event on APS-2-79 postoperative 7th day, and thereafter, he was referred to the gastroenterology department for adjuvant therapy. He was noted to be on remission without any complaints during a 9-month followup under proton-pump inhibitors treatment. Open in a separate window Figure 1 Esophagogastroduodenoscopy findings of the patient: a tight stricture with mucosal edema and the longitudinal ulcerations in the duodenal bulb with a near-complete obstruction. Open in a separate window Figure 2 Foci of villous blunting, glandular destruction, mixed chronic inflammatory infiltrate in lamina propria, and cryptitis (H&Ex200). Open in a separate window Figure 3 Pyloric metaplasia at the base of the crypt (H&Ex400). 3. Discussion Crohn’s disease is a chronic and inflammatory disease characterized by the segmented, transmural involvement of the alimentary tract that can affect any part of the system from the mouth to the anus [10]. Patients with DCD usually present with Crohn’s disease affecting other areas of the gastrointestinal tract; however, isolated DCD is a very rare clinical entity [1, 4]. Initially, patients with DCD are managed with a combination of antiacid and immunosuppressive therapy. However, medical treatment fails in the majority of DCD patients, and surgical intervention is required in case of complicated disease. The most common indication for surgical intervention is progressive obstruction, failure of medical management with intractable pain, bleeding, perforation, and fistulous disease [1, 5, 6]. Options for surgical treatment of complicated DCD disease include resection, bypass, or strictureplasty. Resection procedure that was described by Allen Whipple has been associated with significant morbidity and mortality. Short gut syndrome, diarrhea, chronic malnutrition, electrolyte derangements, vitamin deficiencies, and chronic anemia are the complications of resection [5, 11]. Because of high rates of morbidity and mortality, bypass procedures and strictureplasty have been considered as standard surgical options to preserve the duodenum and prevent related complications of surgical resection. Strictureplasty was introduced by Lee and Papiaoannu in the 1970s and furthermore popularized by Alexander-Williams [12, 13]. The most common strictureplasty techniques for DCD are the Heineke-Mikulicz procedure for shorter strictures and the Finney strictureplasty for longer segments of disease [11]. In the early 1990s, strictureplasty techniques were preferred constantly over bypass procedures due to reliability, safety, and efficacy with their own pitfalls. However, due to the complexity of the strictureplasty arising from the retroperitoneal location of the duodenum and need for extensive mobilization of the duodenum, bypass procedures have been preferred recently. Although bypass procedures are more technically feasible and safe compared to strictureplasty, they.