What endoscopic findings on upper gastrointestinal (esophagogastroduodenoscopy) can indicate Crohn disease?

Upper Endoscopy Findings in Crohn's Disease

Yes, upper endoscopy can reveal Crohn's disease in 3-16% of adults and up to 30-75% of children, though routine upper endoscopy is not recommended for adults unless they have upper GI symptoms. 1

When Upper Endoscopy Is Indicated

Adults with Crohn's disease should undergo upper endoscopy only if they have upper GI symptoms such as dysphagia, odynophagia, nausea, vomiting, or epigastric pain. 1 Routine screening in asymptomatic adults is not recommended because upper GI involvement requiring treatment is uncommon. 1

All pediatric and adolescent patients (<17 years) with suspected or confirmed Crohn's disease should undergo upper endoscopy as part of their initial diagnostic workup, regardless of symptoms, because upper GI involvement is significantly more common in this age group and suggests a more aggressive disease phenotype. 1, 2

Endoscopic Findings Suggestive of Crohn's Disease

When upper endoscopy is performed, the following findings suggest Crohn's disease:

Esophageal Findings

• Aphthoid ulcers or erosions (seen in approximately 15% of patients) 3
• Deep linear ulcerations with focal inflammation extending to the submucosa 4
• Strictures causing dysphagia (rare but may require dilation or surgical resection) 1

Gastric Findings

• Chronic erosions in the antrum or body/fundus (most predictive endoscopic finding for granulomas) 3
• Aphthoid erosions and ulcerations (more frequent in Crohn's than controls) 5, 4
• Mucosal nodularity or cobblestoning 5
• Thickening of gastric folds 5
• Bamboo joint-like appearance (highly suggestive) 2

Duodenal Findings

• Aphthoid lesions 3, 5
• Ulcers and stenosis (significant predictive value for granulomas) 3
• Mucosal erythema and edema 3, 5
• Longitudinal ulcers 2

Histologic Findings on Biopsy

Biopsies must be obtained from both abnormal-appearing and normal-appearing mucosa because histologic changes can be present even when the endoscopic appearance is normal. 4, 6

Highly Specific Findings

• Non-caseating granulomas are the hallmark histologic feature, found in 19.5-40% of upper GI biopsies in Crohn's patients. 3, 5, 7 These are most commonly found in the gastric antrum (15.6%) and body/fundus (3.4%). 3
• Focally enhanced gastritis (focal chronic inflammation) is highly suggestive of Crohn's disease. 8, 2

Supportive Findings

• Focal inflammation in the stomach and duodenum occurs more frequently in Crohn's than in controls. 4
• Duodenal cryptitis (neutrophilic infiltration of crypts) was seen in 26% of pediatric Crohn's patients but not in ulcerative colitis. 7
• Chronic gastritis (92% of Crohn's patients vs. 27% of controls) 7
• Duodenitis (33% of Crohn's patients vs. 9% of controls) 7

Critical Biopsy Protocol

Obtain at least 2 biopsies from the esophagus, multiple biopsies from both the gastric antrum and body/fundus, and multiple biopsies from the duodenum, clearly labeling each anatomic site. 1, 6 This comprehensive sampling is essential because granulomas may be focal and easily missed with limited biopsies. 3

Clinical Implications and Pitfalls

Upper GI involvement in Crohn's disease is more common in younger patients, those with enterocolic disease, and those with shorter disease duration. 3 The presence of upper GI Crohn's disease may indicate a more aggressive phenotype requiring closer monitoring. 1

A common pitfall is performing endoscopy without obtaining biopsies from normal-appearing mucosa. Histologic abnormalities are frequently present despite normal endoscopic appearance, and granulomas can be found in 11% of patients with endoscopically normal upper GI tracts. 5, 4

Endoscopic lesions alone are insufficient for diagnosis—histologic confirmation is required because many upper GI findings (erosions, erythema, edema) are nonspecific and can occur in other conditions. 6, 5