Colonic cancer and Crohn's disease

Historical Perspectives: Malignancy in Crohn's Disease and Ulcerative Colitis

While both Crohn' disease (CD) and ulcerative colitis (UC) are known to predispose patients to certain intestinal malignancies, the exact mechanism of carcinogenesis remains unknown and optimal screening guidelines have not been established. This article will explore the history of our understanding of intestinal malignancy in inflammatory bowel disease (IBD). To contextualize the medical community's difficulty in linking each condition to cancer, the first section will review the discovery of CD and UC. Next, we discuss early attempts to define IBD's relationship with small bowel adenocarcinoma and colorectal cancer. The article concludes with a review of each disease's surgical history and the ways in which certain procedures produced poor oncologic outcomes.

Changing Paradigms in Detection of Dysplasia and Management of Patients With Inflammatory Bowel Disease: Is Colectomy Still Necessary?

This review chronicles the evolution of dysplasia detection and management in inflammatory bowel disease since 1925, the year the first case report of colitis-related colorectal cancer was published. We conclude that colorectal cancer prevention and dysplasia management for patients with inflammatory bowel disease has changed since this first case report, from somewhat hopeless to hopeful.

Mechanisms of Immune Signaling in Colitis-Associated Cancer

The inflammatory bowel diseases ulcerative colitis and Crohn's disease are associated with an increased risk for the development of colorectal cancer. During recent years, several immune signaling pathways have been linked to colitis-associated cancer (CAC), largely owing to the availability of suitable preclinical models. Among these, chronic intestinal inflammation has been shown to support tumor initiation through oxidative stress-induced mutations. A proinflammatory microenvironment that develops, possibly as a result of defective intestinal barrier function and host-microbial interactions, enables tumor promotion. Several molecular pathways such as tumor necrosis factor/nuclear factor-κB or interleukin 6/signal transducer and activator of transcription 3 signaling have been identified as important contributors to CAC development and could be promising therapeutic targets for the prevention and treatment of CAC.

Prevalence of inflammatory bowel disease related dysplasia and cancer in 1500 colonoscopies from a referral center in northwestern Greece

BACKGROUND AND AIM

To report on the prevalence of inflammatory bowel disease (IBD) related intestinal dysplasia and cancer in northwestern Greece.

PATIENTS AND METHODS

Single referral center retrospective study. The policy among all gastroenterologists of the area regarding medical treatment, patient follow up and bowel surveillance strategies including risk factors is the same.

RESULTS

We analyzed 1494 colonoscopies from 696 consecutive IBD patients (494 UC). The follow up time [median, IQR] was 16 [8-23] years and the age at diagnosis was 28 [21-49] years. The number of patient years at risk was 16.219. Disease location for UC was: pancolitis 761 (59%), left sided colitis 455 (35%), and proctitis 69 (6%). Disease location for CD was: colitis 142 (66%), ileitis 45 (22%) and ileocolitis 21 (10%). Disease activity was in remission in 1240 (83%) of them. In total, 498 (72%) patients were on mesalazine, 169(24%) on immunosuppression and 29 (4%) on biologicals. Biopsies were taken randomly in 1429 (96%) endoscopies and were targeted in 65 (4%) of them. We recorded 69 (9.4%) cases with dysplasia and 10 (1.4%) cases with intestinal cancer (9 in UC). No difference was found for dysplasia and cancer in patients who followed up for 10-20 years or for more than 20 years.

CONCLUSIONS

The prevalence of dysplasia and cancer is increased in UC compared to CD but the prevalence of high-grade dysplasia is comparatively low. Intestinal cancer prevalence is increasing after the first decade and then practically remains stable.

Immunosuppressive disorders and risk of anal squamous cell carcinoma: a nationwide cohort study in Denmark, 1978-2005

Compromised immune function may increase the risk of anal squamous cell carcinoma (SCC). We examined the risk of anal SCC in patients with HIV infection and other chronic disorders associated with immunosuppression. A population-based cohort study was conducted using the Danish National Patient Registry and the Danish Cancer Registry (DCR). We identified all patients with a first-time hospital contact or procedure for HIV infection, solid organ transplantation or autoimmune disease or a first-time record of haematologic malignancy in the DCR, 1978-2005, and followed these for a subsequent anal SCC, starting follow-up 1 year after diagnosis of the index disease. Standardised incidence ratios (SIRs) were computed as the ratio of observed to expected numbers of anal SCCs, based on national age-, sex- and period-specific rates. Among 4,488 patients with HIV, we observed 21 anal SCCs with 0.3 expected (SIR: 81.1 (95% confidence interval (CI): 51.6-121.9)). Risk of anal SCC was markedly increased among 5,113 solid organ recipients (SIR: 14.4 (CI: 7.0-26.4)) and 30,165 patients with haematologic malignancies (SIR: 2.3 (CI: 1.1-4.2)) but only moderately increased among 242,114 patients with autoimmune diseases (SIR: 1.3 (CI: 1.0-1.6)). SIRs varied according to type of autoimmune disease and were high in patients with Crohn's disease (SIR: 3.1 (CI: 1.2-6.4)), psoriasis (SIR: 3.1 (CI: 1.8-5.1)), polyarteritis nodosa (SIR: 8.8 (CI: 1.5-29.0)) and Wegener's granulomatosis (SIR: 12.4 (CI: 2.1-40.8)). In conclusion, we found HIV infection, solid organ transplantation, haematologic malignancies and a range of specific autoimmune diseases strongly associated with increased risk of anal SCC.

Carcinoma arising in enterocutan fistulae of Crohn's disease patients: description of two cases

Rarely, carcinoma arises from the fistulous tract of Crohn's disease. Adequate radiological examination often produces misleading pseudonegative findings. We reported two cases of fistula cancers treated with infliximab. The short time-span between the administration of this drug and the diagnosis of cancer makes the correlation between the two unlikely.

Inflammatory bowel disease-related dysplasia and cancer: A referral center study in northwestern Greece

BACKGROUND: An increased risk of colorectal cancer in ulcerative colitis (UC) and Crohn's disease (CD) has been reported. No data on inflammatory bowel disease (IBD)-related dysplasia and cancer is available in Greece, where the disease profile seems to be milder than that of northern Europe. METHODS: A study was conducted of 215 IBD patients (182 with UC, 33 with CD) from a referral center. Patients were followed up for 3-18 years. The prevalence of cancer and dysplasia among the IBD patients who were diagnosed in northwestern Greece was analyzed and registered. Statistical analysis was performed assuming that this IBD cohort had the same risk of developing malignancies as the general population in Greece. RESULTS: Six of the 215 patients in this IBD cohort had cancer, and 20 of 126 patients for whom bowel biopsies were available had dysplasia. Three of these cases were high-grade dysplasia. There was no significant difference in the numbers of calculated and expected cases of IBD-related cancer at any sites except for the skin [2.7 vs. 2.0]. CONCLUSIONS: This IBD cohort did not appear to have an increased risk of cancer during the time period studied. It would be interesting to re-assess the risk after the second and third decades of follow-up.

Risk of cancer in inflammatory bowel disease (IBD)

Patients with inflammmatory bowel disease (IBD) have been reported to have an increased risk of colorectal cancer. Yet, the quantitation of the risk varies widely from one study to the next. This is most likely due to biases in the assessment of cancer risk in IBD, namely, a relatively low prevalence of IBD-related cancer and the clinically heterogeneous nature of IBD in the population. Total proctocolectomy also changes the natural history of IBD-related cancer. Ulcerative colitis (UC)-related cancer is more probable in total and extensive colitis and occurs approximately a decade after diagnosis. Crohn's disease-related colorectal cancer is reported in many, but not all, studies, and the relative risk differs between hospital- and population-based studies. IBD-related cancer is relatively uncommon in childhood; however, this is also a subject of debate. There are no data on the incidence of IBD-related cancer in Europe as a whole; there are only separate studies. A reduced risk for UC-related cancer in patients treated with anti-inflammatory drugs has been reported. The two main strategies for preventing IBD-related cancer are prophylactic colectomy and colonoscopic surveillance. To date, there have virtually been no cost-effectiveness analyses and no studies regarding total disease outcome or patient's quality of life with either strategy. No controlled, prospective trials have been reported in the literature. UC patients with familiar predisposition for colorectal cancer and with concomitant primary sclerosing cholangitis are groups at high risk for IBD-related cancer. Cancer risk in IBD has to be reinvestigated and properly estimated with population-based studies in several areas with standard methods already described.

Colorectal adenocarcinoma in Crohn's disease: a retrospective histologic study

PURPOSE

The aim of this study was to review all histopathologic sections from surgical specimens with inflammatory bowel disease and colorectal carcinoma filed at this hospital between 1951 and 1996.

METHOD

A total of 40 surgical (n = 39) or autopsy (n = 1) colon or colorectal specimens were reviewed. Internationally accepted histologic criteria were strictly applied to differentiate Crohn's disease (CD), ulcerative colitis (UC), and indeterminate colitis (IC).

RESULTS

Of the 40 specimens with inflammatory bowel disease and carcinoma, 22 (55 percent) had CD, 16 (40 percent) had UC, and the remaining 2 (5 percent) had IC. Males accounted for 72.7 percent or 16 of the 22 patients with colorectal carcinoma in CD and for 68.7 percent or 11 of the 16 patients with carcinoma in UC. Both patients with IC and carcinoma were males. The median age of patients at diagnosis was as follows: CD, 20 (range, 7-68) years; UC, 23 (range, 5-21) years. In IC, the age was 61 and 81 years, respectively. The median disease duration (before detection of colorectal cancer) was as follows: CD, 18.5 (range, 1-45) years; UC, 19 (range, 6-38) years. For cases with IC, it was 13 and 19 years, respectively. Median age of patients at cancer diagnosis was as follows: CD, 48 (range, 21-78) years; UC, 49 (range, 21-81) years. Ages at cancer diagnosis in IC were 68 and 81 years. Colorectal carcinoma tend to develop among relatively young patients with CD and UC. Mucinous adenocarcinomas accounted for approximately one-third of the carcinomas affecting CD. Thirty percent of old specimens (before the end of 1982) had in fact carcinoma complicating CD and not UC (the latter being the diagnosis appearing in old pathologic reports). During a time lapse of 38 years (i.e., between 1951 and 1989), only 11 cases of colorectal CD with carcinoma (i.e., 0.2 cases/year) were found, but as many as 11 during the past 6.5 years (i.e., 1.7 cases/year) have been diagnosed. Only 42.3 percent (11/26) of cases with colorectal inflammatory bowel disease and carcinoma operated on between 1951 and the end of 1989 had Crohn's colitis but as many as 78.6 percent (11/14) of those operated on between 1990 and May 1996 had Crohn's colitis. Review of the literature indicated that 64.8 percent or 191 of the 295 cases of colorectal carcinomas in CD so far reported occurred in the past 6.5 years. It would seem as if the risk of colorectal carcinoma in Crohn's colitis has increased in later years.

CONCLUSIONS

1) Reports on cancer frequency in UC based on old histopathologic records should be subjected to critical histologic re-evaluation; 2) carcinoma in Crohn's colitis has increased at this hospital, particularly since 1990; 3) the surveillance program strategy used in patients with long-standing UC at this hospital should also embrace patients with Crohn's colitis.

Development of mucinous adenocarcinoma in chronic Crohn's disease fistulae without luminal involvement

A patient with Crohn's disease who developed mucinous adenocarcinoma in chronic fistulae is reported. Malignancy may complicate chronic nonhealing Crohn's sinus tracts and fistulae, even with no mucosal involvement by carcinoma. Persistent non-remitting perianal induration and pain should alert the physician to the possibility of underlying malignancy. Prompt examination under anesthesia and biopsy or fine-needle aspiration may facilitate diagnosis and therapy of the carcinoma at an early stage.

Similarity of colorectal cancer in Crohn's disease and ulcerative colitis: implications for carcinogenesis and prevention

Colorectal cancer is the most frequent malignant complication in patients with inflammatory bowel disease. Eighty patients with colorectal cancer complicating Crohn's disease (CD) or ulcerative colitis (UC) with median ages at diagnosis of colorectal cancer of 54.5 years and 43.0 years respectively were studied. The median duration of disease to the diagnosis of cancer was long (CD 15 years; UC 18 years). Most cancers developed after more than eight years of disease (CD 75%; UC 90%). Patients with multiple carcinomas at diagnosis were equally common (CD 11%; UC 12%). Carcinoma occurred in the area of macroscopic disease in most patients (CD 85%; UC 100%). Mucinous and signet ring histological features were equally common (CD 29%; UC 21%). Dysplasia was present with similar frequency in both diseases (CD 73%; UC 79%). The overall five year survival rates were also similar (CD 46%; UC 50%). These findings show that carcinomas complicating CD and UC have strikingly similar clinicopathological features and suggest that a common underlying process, such as chronic inflammation, maybe important in the pathogenesis of colorectal carcinoma.

Lower gastrointestinal malignancy in Crohn's disease

An increased incidence of carcinoma of the small bowel and colon has been described in patients with Crohn's disease. Tumours arising in the rectum and anus are reported less often. Between 1940 and 1992, of some 2500 patients with Crohn's disease seen at this hospital, 15 are known to have developed carcinoma of the lower gastrointestinal tract. Malignancy occurred in the colon in two patients, in the upper two thirds of rectum in one, in the lower third of rectum in seven, and in the anus in five. The 12 patients with carcinoma arising in the anus or lower rectum had longstanding severe anorectal Crohn's disease, which included a stricture in four, fistula in four, proctitis in one, abscess in two, and enlarged anal skin tags in one. The development of malignancy in patients with Crohn's disease may apply particularly to those with chronic complicated anorectal disease.

Increased risk of large-bowel cancer in Crohn's disease with colonic involvement

A cohort of 1655 patients with Crohn's disease diagnosed during 1983 in the Uppsala health care region, Sweden, was followed up with respect to the occurrence of colorectal cancer to the end of 1984. 12 colorectal cancers were diagnosed, yielding an increased overall risk of 2.5. The relative risk was similar for males and females. Duration of follow-up did not affect risk. Relative risk for disease of the terminal ileum only was 1.0; for terminal ileum and parts of colon 3.2; and for colon alone 5.6. Patients in whom Crohn's disease was diagnosed before age 30 with any colonic involvement at diagnosis had a higher relative risk (20.9) than those diagnosed at older ages (2.2).

Gastrointestinal malignancies in Crohn's disease. A 20-year experience

The relationship between gastrointestinal neoplasms and Crohn's disease is poorly defined. The purpose of this study was to characterize the features of gastrointestinal malignancies that developed in Crohn's patients. In this retrospective review the authors identified six patients with Crohn's disease who developed such lesions over a 20-year period: four patients had colorectal cancers and two had ileal malignant neoplasms. Patients averaged 52.7 years of age (range, 21 to 61 years). Three patients were men and three women. Five of the six patients had endured Crohn's disease for more than 20 years. Only two lesions were diagnosed before surgery. The colorectal lesions were predominantly right-sided and all occurred in bowel segments with active Crohn's disease. The lesions demonstrated aggressive histologic features: three of six tumors were poorly differentiated, one of the five adenocarcinomas was mucinous, and three of the colorectal cancers were Dukes' B or C lesions. Four of six patients survived five or more years. There was a single malignant carcinoid, which represents the seventh case report of a carcinoid tumor occurring in a patient with Crohn's disease. This study indicates that patients with Crohn's disease develop a wide variety of small bowel and colorectal cancers. Furthermore, it suggests that Crohn's patients with colonic disease should periodically undergo surveillance colonoscopy.

Malignant lymphoma, immunoblastic with plasmacytic differentiation, complicating Crohn's disease

A case of malignant lymphoma (immunoblastic with plasmacytic differentiation) of the colon complicating Crohn's disease is reported. The rarity of this complication in inflammatory granulomatous disease of the intestine is stressed. The possible relationship between intestinal lymphoma and Crohn's disease is discussed.

Colorectal carcinoma in patients with Crohn's disease

Epidemiologic studies have shown a fourfold to 20-fold increased risk of colorectal carcinoma in patients with Crohn's disease as compared with the general population, but management for this risk is controversial. This paper presents a series of 10 patients with Crohn's disease and colorectal carcinoma from one institution and a review of the literature. Compared with 118 consecutive patients having colorectal carcinoma of the usual type at the same institution, the 10 patients were younger (mean age 55 vs. 65 yr, p less than 0.05) and had a higher prevalence of mucinous carcinoma (50% vs. 9%, p less than 0.01), providing evidence in addition to the previous epidemiologic results that Crohn's disease is a predisposing (premalignant) condition for colorectal carcinoma. Eight of the 10 patients had an antecedent history of Crohn's disease, ranging from 4 to 51 yr (mean 24 yr); 2 patients presented with colorectal carcinoma and were found to have Crohn's disease. Of particular note, 9 of the 10 patients had colitis or ileocolitis, and carcinoma occurred in bypassed rectum in 2 patients. One patient had two carcinomas. Three of the 11 carcinomas were not recognized preoperatively. The anatomic sites of the cancers were not significantly different from usual colorectal carcinoma, with 7 of the 11 tumors (64%) in the sigmoid colon and rectum. Dysplasia was identified in all 10 patients, and all of the 10 resected carcinomas were found to be contiguous with high-grade dysplasia. The findings in this study support the proposals based upon epidemiologic data that surveillance should be considered for patients with clinically evident colorectal involvement by Crohn's disease or a bypassed segment of colorectum.

The relationship between fistulas in Crohn's disease and associated carcinoma. Report of four cases and review of the literature

Patients with carcinoma involving chronic fistulizing Crohn's disease may have developed the malignancy due to chronic epithelial irritation at either end of the fistula tract. Alternatively, the carcinoma may be the cause of the fistula. Examples of each type of relationship are presented in the reports of four patients from our institution and supported by a review of the literature. The diagnoses of such carcinomas are often delayed due to lack of specificity of symptoms and signs. A high index of suspicion and regular surveillance of high-risk patients are recommended.

Cancer in Crohn's disease--an 'occult' malignancy

The purpose of this case report of cancer complicating Crohn's disease is to highlight the occult nature of these tumours. From the literature it is apparent that the majority are only discovered by the pathologist. As many are inconspicuous even on macroscopic examination an improved method of dissection is suggested.

Cancer in the excluded rectum following surgery for inflammatory bowel disease

The procedure of choice in the emergency surgical management of ulcerative colitis and Crohn's colitis is often subtotal colectomy and ileostomy. Further surgery of the retained rectum may be delayed, sometimes for many years. The risk of malignant change in ulcerative colitis is well documented; the cancer risk seems to be much less in Crohn's disease. Five cases are reported where carcinoma developed in the out-of-circuit rectal stump after subtotal colectomy, three cases of ulcerative colitis, and two of Crohn's disease. The importance of regular surveillance or removal of an excluded rectum is emphasized.

A comparison of cancer risk in Crohn's disease and ulcerative colitis

The authors estimated cancer risk among 589 patients hospitalized with Crohn's disease between 1960-1976 by calculating the ratios of observed number of cancers (O) in our hospital sample to the expected number of cancers (E) based on the age- and sex-specific cancer rates of a standard population. The authors then compared these O/E ratios with the O/E ratios similarly calculated among 267 patients hospitalized with ulcerative colitis. The risk of colorectal cancer was significantly increased in Crohn's disease (O/E = 6.9, P less than 0.001). This increase was similar in magnitude to that found in left-sided ulcerative colitis (O/E = 8.6, P less than 0.001) but was much less than that found in universal ulcerative colitis (O/E = 26.5, P less than 0.001). The incidence of small bowel cancer was greatly increased in the combined group of regional enteritis and ileocolitis (O/E = 85.8, P less than 0.001), and even more so in the regional enteritis group alone (O/E = 114.5, P less than 0.001). The incidence of extraintestinal cancer did not increase in any of the patient groups.

Adenocarcinoma in perineal fistulas of Crohn's disease

Until recently, Crohn's disease has not been regarded as a premalignant lesion, but the increasing number of patients with Crohn's disease in whom adenocarcinoma of the gastrointestinal tract develops strongly suggests that these patients are indeed at a higher risk for carcinoma. These patients are usually young and tend to develop a malignancy in the bypassed ileum or right colon. Patients with such lesions usually have a poor prognosis. Adenocarcinoma arising in perineal fistulas secondary to Crohn's disease has not been reported in English medical literature except for one case published in 1975. In this article, the authors report a second, similar case of Crohn's disease with recurrent perineal fistulas. An infiltrating adenocarcinoma developed in these fistulas, in the anorectal region, and in the left labia. The risk of malignancy should be seriously considered in the management of Crohn's disease, especially in young patients. Because of the risk of adenocarcinoma in these patients, resection rather than bypass is recommended in the surgical management.

Patterns of neoplasia in Crohn's disease and ulcerative colitis

Cancer occurred in 28 of 579 patients (4.8%) with Crohn's disease (CD) and in 30 of 267 (11.2%) with ulcerative colitis (UC) admitted to the Mount Sinai Hospital between 1960--1976. The proportion of cancers that were extraintestinal was greater in CD than in UC (43 vs. 12%), as was the proportion of gastrointestinal cancers that arose in apparently normal bowels (33 vs. 4%). The incidence of gastrointestinal cancer increase with duration of disease in both CD and UC, but the absolute rates were three times higher in UC. For extraintestinal cancer, on the other hand, there was less correlation with increasing duration of disease, and no higher frequency in UC than in CD. Mortality from gastrointestinal cancer was 82% in CD and 50% in UC, but occurred only within two years of tumor diagnosis; survival beyond two years seemed to indicate a favorable prognosis.

Adenocarcinoma in Crohn's colitis

A case of Crohn's disease with carcinoma of the rectum is reported, bringing the number of reported cases to 44. Although the exact incidence of carcinoma arising in a segment of Crohn's disease is not known, a review of the literature emphasizes that there does seem to be a definite increased risk.

Ileorectal anastomosis for inflammatory disease of the colon

We have reported long-term results in the cases of 42 patients following total colectomy and ileorectal anastomosis for inflammatory bowel disease. In this group, 35 patients had Crohn's disease and seven had ulcerative colitis. Five of those seven patients with ulcerative colitis had carcinoma of the colon at the time of colectomy. A diverting loop ileostomy was constructed in 14 of the 35 patients who had Crohn's colitis at the time of operation, and none of these patients had any anastomotic leakage either before or after the ileostomy was closed. However, there patients with Crohn's colitis in whom anastomotic leaks developed postoperatively; all three patients died. In the group with ulcerative colitis, one patient had an anastomotic leak but there was no operative nortality. Of the 29 patients with Crohn's disease followed for one to 18 years, 12 (41 per cent) developed recurrences in the ileum and/or rectum, and seven of these patients had to have their anastomoses taken down.

Carcinoma complicating Crohn's disease. Report of seven cases and review of the literature

Seven cases of adenocarcinoma complicating Crohn's disease are reviewed. In three of the patients, small bowel cancers developed in association with reginal enteritis. In four patients, carcinoma of the colon was superimposed on Crohn's colitis. In two of these, the adenocarcinoma infiltrated chronic colocutaneous fistulas. Review of the literature shows an increasing number of reports of carcinoma complicating Crohn's disease, with a total of 36 cases of small bowel cancer and 30 cases of colon cancer previously reported. The significane of these and our own cases is discussed. The possibility of carcinoma must be kept in mind by clinicians following patients with Crohn's disease. Adenocarcinoma complicating Crohn's disease occurs at a younger age, on the average, and in areas similar to the distribution of Crohn's disease rather than the usual distribution of the cancer. Preoperative diagnosis is difficult, but changes in the nature of chronic fistulas should be investigated.

Carcinoembryonic antigen in patients suffering from ulcerative proctocolitis

Carcinoembryonic antigen (CEA) has been measured by radioimmunoassay in samples obtained from all patients suffering from ulcerative proctocolitis and seen within a four-month period. The characteristics of this group of patients have been compared with reported epidemiological studies in this disease, and have been found to have a similar sex ratio and age of onset, but a more limited disease. Among 59 patients, 11 were found to have elevated circulating CEA values. One of the 11 had a colonic carcinoma and another was pregnant. Excluding these two patients, an overall prevalence of elevated CEA levels of 17.5% was found. The prevelance in ulcerative proctitis was 7.1%, and in colitis was 19.9%. The patients in whom elelvated plasma CEA values were found were compared with the remaining patients in relation to factors known to be associated with an increased propensity for the development of colorectal carcinoma complicating ulcerative colitis. There was no difference in mean age of the patients at disease onset, nor was there any difference in disease duration, extent, and control. A significant correlation was found between elevated plasma CEA levels and the severity of the initial attack. One patient with premalignant changes in the rectal mucosa had consistently normal concentrations of plasma CEA. There was no significant correlation between elevated plasma CEA values and disease activity. The mean age of the two groups of patients was similar. No carcinoma has manifested in any patient during follow-up periods of at least 18 months.

Inflammatory bowel disease: the surgical pathology of Crohn's disease and ulcerative colitis

Ulcerative colitis and granulomatous colitis are distinct entities, but up to 10 per cent of colectomy specimens remain unclassified. Ulcerative colitis is primarily a mucosal disease, and other changes appear to be secondary to this process. By contrast, Crohn's disease, or granulomatous colitis, involves the whole thickness of the bowel wall. About 20 per cent of the cases of Crohn's disease involve the small and large bowel, while another 20 per cent are restricted to the large bowel. Since granulomatous colitis is a patchy disease, and many of the changes are deep within the bowel wall, rectal biopsy may not be as helpful as in ulcerative colitis. Fully developed granulomas are present in only a small minority of cases, and a diagnostic report of granulomatous colitis may be given in the absence of granulomas. In biopsy material, the differentiation of inflammatory bowel disease from ischemic colitis and pseudomembranous colitis may be difficult. In the absence of specific demonstration of an organism it may also be impossible on rectal biopsy to distinguish amebic or bacillary dysentery from ulcerative colitis. Even by colectomy, 29 of 300 specimens were sufficiently atypical so as not to warrant a label of Crohn's disease, or ulcerative colitis. Cancer of the colon, which is common in ulcerative colitis, is rare in Crohn's disease, but may also represent a definite complication in the latter. Immunologic studies are still confusing, but it is suggested that patients with ulcerative colitis and Crohn's disease may have a state of altered immunologic reactivity.

Non-restorative surgery in the treatment of Crohn's disease of the large bowel

This study gives detailed information on the two principal groups of patients undergoing excisional surgery with a permanent artificial stoma for Crohn's disease of the large bowel. During the years 1952-71, 64 patients were treated by total proctocolectomy and ileostomy and 26 patients by excision of the distal large bowel and colostomy. In the group of patients undergoing proctocolectomy, there were two postoperative and six late deaths. Of the 56 patients alive at the end of the follow-up period (average length of follow-up 8.1 years), four had shown evidence of recurrent disease. In each case this occurred following a staged proctocolectomy and at, or immediately proximal to, the ileostomy: the shortest interval between surgery and recurrence was just under 10 years. AMONG THE PATIENTS TREATED BY EXCISION OF THE DISTAL LARGE BOWEL, THERE WERE TWO UNRELATED LATE DEATHS: with an average duration of follow up of 7.3 years, recurrent disease occurred in only one of the 24 patients alive at the concluding date for this study.

Adenocarcinoma and Crohn's disease. A report of 2 cases and analysis of the literature

Two cases of carcinoma developing in a segment of Crohn's disease are described, one in the large intestine and one in the small intestine. From an analysis of the literature, evidence is advanced with regard to age at the time of developing carcinoma, duration of symptoms attributable to Crohn's disease, anatomical distribution, and observed incidence compared with chance incidence. It is concluded that there is a small but significant risk of carcinoma developing, both in the small and large intestines, in Crohn's disease.

Metachronous development of regional enteritis of the colon in a patient with ulcerative colitis

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