Topical Treatment of Refractory Esophageal Crohn’s Disease With Stricture Using Budenoside Capsules

Introduction: Fifty-nine-year-old male with long standing Crohn’s disease complicated by perianal fistulas and multiple exacerbations managed with infliximab presented with progressive dysphagia, odynophagia, and 20 lb weight loss. Patient underwent a barium swallow revealing an 8.8 cm stricture in the mid-esophagus (Figure 1). He underwent an upper endoscopy that confirmed a tight mid-esophagus stricture with fistula formation and ulceration, which could not be traversed (Figure 2). Attempt at dilation was unsuccessful and surgical PEG was placed for nutrition. Biopsies showed acute esophagitis with marked chronic lymphocytic inflammation that were consistent with active Crohn’s disease. Patient was then started on 9 mg of budenoside daily. He was advised to chew on the capsules and swallow them mixed in apple sauce. After 2 months of therapy, a repeat EGD showed marked improvement of his stricture with easy passage of the endoscope (Image 3) and the PEG was reversed. After 5 months, patient has maintained his weight on budenoside and infliximab. Esophageal involvement in Crohn’s disease is rare. Topical budenoside therapy has been used for mild esophageal disease. When complicated by severe esophageal stricture, patients often undergo surgery. This is the first case of success with oral budenoside treatment in severe, refractory esophageal Crohn’s disease with stricture.Figure 1