Two Cases of Crohn’s Disease Presenting as Granulomatous Gastritis

Background: Granulomatous gastritis is an uncommon histological finding characterized by the presence of granulomas in the gastric mucosa. While granulomatous inflammation in the stomach can be attributed to a variety of causes, one rare but possible cause is Crohn’s disease. Crohn’s disease (CD) is a chronic inflammatory disorder primarily affecting the gastrointestinal tract, typically involving the terminal ileum and colon. However, isolated gastric involvement is rare and can create diagnostic difficulties. Patients with gastric Crohn’s disease may present with symptoms like peptic ulcer disease, including epigastric pain, nausea, vomiting, and potential gastric outlet obstruction. Endoscopy may reveal mucosal irregularities, ulcers, and strictures and the histology of Biopsies showing non-caseating granulomas is suggestive, though not pathognomonic, of Crohn’s disease. To confirm the diagnosis, other causes such as infection, sarcoidosis, and other potential causes of granulomas should be ruled out. Aim: The primary objective of this study is to elucidate the clinical presentation, diagnostic challenges, and management strategies associated with rare cases of granulomatous gastritis as the initial manifestation of Crohn’s disease. Case Presentation: We report two cases of Crohn’s disease initially manifesting as granulomatous gastritis, an uncommon presentation that underscores the need for a thorough differential diagnosis when encountering granulomatous inflammation in the stomach. The clinical presentation of the two patients was not specific (epigastric pain, nausea, and weight loss). The esophagogastroduodenoscopy revealed in the two cases an erythematous and nodular gastric mucosa of the antrum and the fundus. The histopathological analysis demonstrated non-caseating granulomas. The secondary etiologies of granulomatous gastritis were ruled out and an ileo-colonoscopy was performed for the two patients. The two patients were initially treated with corticosteroids, to which they exhibited a primary response, and were subsequently placed on maintenance therapy. Conclusion: Gastric Crohn’s disease, while rare, is an established clinical and pathological entity. Isolated granulomatous gastritis can serve as an initial indicator of Crohn’s disease; however, it alone is insufficient for a definitive diagnosis. A presumptive clinical diagnosis becomes more reliable when typical lesions are identified in the ileum or colon, supported by radiologic and endoscopic evaluations. Importantly, as demonstrated in our patients, histological confirmation via endoscopic biopsy can solidify the diagnosis.