Mrs. H.A. is 23 years old, non smoker, have been presenting intermittently for 10 years a chronic diarrhea associated with a dysentery and alteration of general condition. On physical examination, the patient was in a very poor condition (weight = 36 kg), with hemodynamic instability, and clinical symptoms of anemia. Laboratory tests showed microcytic hypochromic anemia at 11.5 g/dl, a sedimentation rate at 31 mm in the first hour and hypoproteinemia to 58 g/l. Abdominal ultrasound showed a peritoneal effusion of middle abundance without evident digestive thickeness. The ileo-colonoscopy showed lesions suggestive of Crohn’s disease with congestive non ulcerated colonic mucosa distributed with intervals of healthy mucosa, whereas the caecum and ileum appeared macroscopically normal. Histological study of colonic biopsies showed a lot of elements suggestive of IBD (abraded surface epithelium with elongation and vertical integration of the crypts, dense polymorphous inflammatory infiltrate in the chorion without crypt abscesses or granulomas and the presence of subacute ileitis with superficial ulceration). Oesogastroduodenal endoscopy showed a crenellated duodenal mucosa with mosaic feature. Histological examination of duodenal biopsies found a celiac disease type 4 according to the classification of Marsh with completely flattened villi, an inflammatory infiltrate in the lamina propria and lymphocytic exocytosis at 56 lymphocytes/100 enterocytes. So, all these examinations have confirmed the association of celiac disease with Crohn’s disease in this first case.

Because the Crohn’s disease was considered inactive according to the Best score, the decision was to start gluten-free diet and complete the management next according to the evolution of the disease. The patient was readmitted next in medical consultation with good clinical response. Gluten-free diet was maintaining and the crohn’s disease was still in remission.

Mr. MM is 55 years old, had surgery two years ago for appendicular plastron (appendectomy not done), since there he has suffered from watery diarrhea with pain in the right iliac fossa and conservation of the general condition. Abdominal examination found a pain at the right iliac fossa. Laboratory tests showed an isolated inflammatory syndrome. Abdominopelvic ultrasound showed an inflammatory thickeness of the digestive tract in the right iliac fossa and ascites of low abundance. The CT enteroclysis showed that this digestive thickeness was at the expense of the last ileal loop. At the ileo-colonoscopy, ileal mucosa was ulcerated and congestive five centimeters long after the ileocecal valve with ileal impassable stricture. The colon was macroscopically normal. Histological examination of ileal biopsies showed lesions of Crohn’s disease in acute exacerbation with the presence of an inflammatory infiltrate of the chorion, granules rich in neutrophils and cryptic abnormalities in type of duplication. During his hospitalization, the patient had epigastric pain justifying an oesogastroduodenal endoscopy which was normal but the histological study of jejunal biopsies found a celiac disease (atrophic mucosa with flattening of the villi, lymphocytosis > 40/100 enterocytes). The antigliadin antibodies were positive (IgA and IgG), whereas the anti-endomysium and anti-transglutaminase antibodies were negative.

So, our patient presented a combination of stenosing active Crohn’s disease interesting the small bowel (Best score at 237) and celiac disease. The search for an associated thyroiditis was negative (TSHus was at 0.60 μUI/ ml). The patient was put on oral corticosteroid therapy at a dose of 1 mg/Kg/day and gluten-free diet. The evolution was marked by a durable good clinical response after 12 months of follow-up; degression of corticosteroids was started after one month of treatment at full dose.