Primary Crohn's disease of the colon and rectum

Time to Revisit Disease Classification in Inflammatory Bowel Disease: Is the Current Classification of Inflammatory Bowel Disease Good Enough for Optimal Clinical Management?

Inflammatory bowel disease (IBD), historically subdivided into Crohn's disease and ulcerative colitis, is a very heterogeneous condition. While the tendency in medicine is to try to reduce complexity, IBD is a disease that cannot justify a one-size-fits-all principle. Our current clinical classification tools are suboptimal and need further refinement to capture, at least in part, the variety of phenotypes encountered in daily clinical practice. Although these revised classification tools alone will not be sufficient and should be complemented by more detailed molecular subclassifications, optimized clinical phenotypes can contribute to improved trial designs, future translational research approaches, and better treatment outcomes. In the current review, we discuss key clinical features important in IBD disease heterogeneity, tackle limitations of the current classification systems, propose some potential improvements, and raise priorities for future research in this domain.

Recent advances in clinical practice: a systematic review of isolated colonic Crohn's disease: the third IBD?

The genetics of isolated colonic Crohn's disease place it approximately midway between Crohn's disease with small intestinal involvement and UC, making a case for considering it as a separate condition. We have therefore systematically reviewed its epidemiology, pathophysiology and treatment. Key findings include a higher incidence in females (65%) and older average age at presentation than Crohn's disease at other sites, a mucosa-associated microbiota between that found in ileal Crohn's disease and UC, no response to mesalazine, but possibly better response to antitumour necrosis factor than Crohn's disease at other sites. Diagnostic distinction from UC is often difficult and also needs to exclude other conditions including ischaemic colitis, segmental colitis associated with diverticular disease and tuberculosis. Future studies, particularly clinical trials, but also historical cohorts, should assess isolated colonic Crohn's disease separately.

The risk of cancer in patients with Crohn's disease

PURPOSE

The risk of cancer in patients with Crohn's disease is not well defined. Using meta-analytical techniques, the present study was designed to quantify the risk of intestinal, extraintestinal, and hemopoietic malignancies in such patients.

METHODS

A literature search identified 34 studies of 60,122 patients with Crohn's disease. The incidence and relative risk of cancer were calculated for patients with Crohn's disease and compared with the baseline population of patients without Crohn's disease. Overall pooled estimates, with 95 percent confidence intervals, were obtained, using a random-effects model.

RESULTS

The relative risk of small bowel, colorectal, extraintestinal cancer, and lymphoma compared with the baseline population was 28.4 (95 percent confidence interval, 14.46-55.66), 2.4 (95 percent confidence interval, 1.56-4.36), 1.27 (95 percent confidence interval, 1.1-1.47), and 1.42 (95 percent confidence interval, 1.16-1.73), respectively. On subgroup analysis, patients with Crohn's disease had an increased risk of colon cancer (relative risk, 2.59; 95 percent confidence interval, 1.54-4.36) but not of rectal cancer (relative risk, 1.46; 95 percent confidence interval, 0.8-2.55). There was significant association between the anatomic location of the diseased bowel and the risk of cancer in that segment. The risk of small bowel cancer and colorectal cancer was found to be higher in North America and the United Kingdom than in Scandinavian countries with no evidence of temporal changes in the cancer incidence.

CONCLUSIONS

The present meta-analysis demonstrated an increased risk of small bowel, colon, extraintestinal cancers, and lymphoma in patients with Crohn's disease. Patients with extensive colonic disease that has been present from a young age should be candidates for endoscopic surveillance; however, further data are required to evaluate the risk of neoplasia over time.

Inflammatory bowel disease and the eye

Inflammatory bowel disease includes Crohn's disease and ulcerative colitis, and is characterized by chronic inflammation of the intestines. The advances in understanding of the inflammatory process have resulted in improved treatment of inflammatory bowel disease. The systemic complications of inflammatory bowel disease involve many organs, eyes included. The ophthalmic complications are usually of inflammatory origin. Some of these complications, like scleritis, may reflect overall disease activity. Treatment of intestinal inflammation-either medical or surgical-usually helps resolution of ophthalmic complications. This review describes recent developments in the diagnosis and management of the inflammatory bowel disease and its ophthalmic complications.

Crohn's colitis-like changes in sigmoid diverticulitis specimens is usually an idiosyncratic inflammatory response to the diverticulosis rather than Crohn's colitis

The clinical outcome and optimum classification of patients who have sigmoid resection specimens that show the histologic features of Crohn's disease (CD) and diverticulitis is not well defined. Historically, these patients were considered to have coexistent diseases, but recent studies have suggested that the CD-like changes are part of the inflammatory reaction of the diverticulitis. Sorting out these issues has been complicated by the lack of distinction between patients with and without CD in other regions of the bowel, short clinical follow-up periods, and small numbers of patients. We report on the clinical outcome and histology of 29 patients who had sigmoid resection specimens with diverticulitis and CD-like changes. Of the 25 patients who had no prior or concurrent CD at the time of surgery, 23 remained free of CD during the follow-up period (median, 6.0 yrs) and two developed CD in other regions of the bowel. All four patients with CD prior to their sigmoid resection continued to have active CD postoperatively. There were no histologic features of the sigmoid resection specimens that could be associated with the outcome of the patient. These results suggest that CD-like changes within the sigmoid resection specimen are an idiosyncratic inflammatory response to the diverticulosis rather than coexistent CD in the overwhelming majority of patients who do not have prior or concurrent CD at the time of sigmoid resection. Pathologists should be wary about making the diagnosis of sigmoid CD in the context of diverticulitis unless there is CD in other parts of the bowel.

The prevalence, anatomic distribution, and diagnosis of colonic causes of chronic diarrhea

BACKGROUND

The prevalence of chronic diarrhea from a colonic disease and the optimal method of its diagnosis have not been ascertained.

METHODS

Eight hundred nine patients with chronic non-bloody diarrhea unassociated with human immunodeficiency virus (HIV) infection underwent colonoscopy with biopsy specimen taken from throughout the colon and, if reached, the terminal ileum. The prevalence and anatomic distribution of ileocolonic histopathology and whether flexible sigmoidoscopy or colonoscopy represents the safest and most cost-effective test for diagnosis were determined.

RESULTS

122 of 809 patients (15%) had colonic histopathology (microscopic colitis in 80 patients, Crohn's disease in 23, melanosis coli in 8, ulcerative colitis in 5, other forms of colitis in 5, and nodular lymphoid hyperplasia in 1). A correct assessment of colonic histology (normal or abnormal) could have been made from biopsies of the distal colon in 99.7% of patients.

CONCLUSION

In a referral setting, colonic histopathology occurs in 15% of patients with chronic diarrhea without HIV infection. According to this prevalence and the nearly universal diffuse anatomic distribution of colonic disease in these patients, a diagnostic investigation for chronic colonic diarrhea using a 60 cm flexible sigmoidoscope is highly efficient and cost-effective.

Colorectal adenocarcinoma in Crohn's disease

OBJECTIVE

The authors' aim was to review the clinical features and estimate the long-term survival of patients with colorectal carcinoma complicating Crohn's disease.

SUMMARY BACKGROUND DATA

Recent studies have demonstrated a significantly increased risk of colorectal carcinoma in patients with Crohns disease.

METHODS

The authors reviewed retrospectively the medical records of 30 patients with Crohn's disease admitted to The Mount Sinai Hospital between 1960 and 1989 in whom colorectal adenocarcinoma developed. All patients were operated on and follow-up was complete for all patients to 10 years after operation, to the time of death, or to the closing date of the study in December 1989.

RESULTS

The 30 patients in the series had 33 colorectal adenocarcinomas; three patients (10%) presented with two synchronous cancers. The patients were relatively young (mean age, 53 years) and had long-standing Crohn's disease (duration >20 years in 87%). The 5-year actuarial survival was 44% for the overall series: 100% for stage A, 86% for stage B, 60% for stage C. All five patients with excluded bowel tumor died of large bowel cancer within 2.4 years; by contrast, the actuarial 5-year survival for patients with in-continuity tumors was 56%.

CONCLUSIONS

The incidence, characteristics, and prognosis of colorectal carcinoma complicating Crohn's disease are similar to the features of cancer in ulcerative colitis, including young age, multiple neoplasms, long duration of disease, and greater than a 50% 5-year survival rate (without excluded loops). These observations suggest the advisability of surveillance programs for Crohn's disease of the colon similar to those for ulcerative colitis of comparable duration and extent.

Inflammatory bowel disease in older patients

The onset of UC and CD may occur later in life. Although making the diagnosis of IBD in the elderly can be challenging, the clinical course, natural history, and response to treatment are similar for older and younger patients. In fact, both UC and CD tend to be less extensive in older patients, a feature that may contribute to the overall favorable prognosis for elderly patients with IBD. Overall mortality rates for both UC and CD appear to be similar to that of the general population except for those few patients that present with severe initial disease. Typical features of IBD in the elderly are summarized in Table 3. The differential diagnosis of IBD in the elderly includes infectious causes of enterocolitis, ischemic colitis, and diverticular disease as well as several other mimics of IBD. Awareness of the possibility of late-onset disease and the unique manifestations of disease in the elderly contributes to accurate diagnosis and timely treatment.

Can Crohn's disease be diagnosed at laparotomy?

The typical macroscopic features of Crohn's disease have been well described and are widely regarded as sufficient to diagnose the disease at laparotomy. We report six patients undergoing laparotomy for symptomatic Crohn's disease, shown radiologically, who were found to have macroscopically normal small bowel despite careful examination of the bowel by an experienced surgeon. In four cases resection was deferred, but all subsequently deteriorated and required further surgery. Minor abnormalities found by balloon examination of the terminal ileum prompted resection in two further patients. Histology showed an unusually superficial distribution of inflammation, which could explain the negative findings at laparotomy. We conclude that normal laparotomy findings alone do not exclude a diagnosis of clinically important small bowel Crohn's disease. Crohn's disease should be considered in patients with persisting symptoms after negative laparotomy.

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.

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.

Segmental ulcerative colitis: a case report and review of the literature

Ulceractive colitis, a chronic diffuse inflammatory disease affecting the mucosa of the colon and rectum, is characterized by ulcerations with bleeding, mucosal crypt abscesses, and inflammatory pseudopolyps. Classically, it begins in the rectosigmoid but often extends to involve the entire colon. It is uncommon to find segmental involvement sparing the rectosigmoid.A case of segmental ulcerative colitis is presented with a brief comparison of segmental ulcerative colitis and segmental Crohn's colitis.

Prognosis after surgical treatment for granulomatous enteritis and colitis

To assess the rate of recurrence of Crohn's enterocolitis, 118 patients with Crohn's disease of the small intestine, the small and large intestine, or only the large intestine who had surgery were assessed. Of 53 patients with disease confined to the small intestine, 25 had recurrence, while 19 of 37 patients with disease of the small and large intestine had recurrence. Of 16 patients with Crohn's disease of the colon who had limited reaction, 11 had recurrence. None of the 28 patients with Crohn's disease of the colon or rectum, followed up for 5 years, had recurrence in the small intestine. This study demonstrates that (1) limited resection for Crohn's disease of the colon leads to a significant recurrence rate, and (2) in patients with Crohn's disease localized to the colon, follow-up for at least 5 years revealed no recurrence in the small intestine.

Prevalence of occult inflammatory bowel disease in ankylosing spondylitis

Fifty-five patients with ankylosing spondylitis and 16 control patients matched for sex and age were examined for evidence of occult inflammatory bowel disease. In all patients evaluation included history and physical examination, barium enema, sigmoidoscopy, and rectal biopsy. The results of this study suggest that there is no increased prevalence of occult inflammatory bowel disease in patients with ankylosing spondylitis.

Ileorectal anastomosis in patients with Crohn's disease of the colon

Thirty-seven patients were studied who had an ileorectal anastomosis performed for Crohn's disease of the colon. Twenty-nine were done as a primary procedure and in eight the anastomosis was made after previous total or segmental colectomy. Three patients developed anastomotic leaks and all three patients died. No patient who had a diverting loop ileostomy performed at the time of ileorectal anastomosis developed anastomotic leaks before or after the ileostomy was closed. Of the 37 patients, three died postoperatively and another five have had less than a one year follow-up. Of the remaining 29 patients, 12 (41%) had recurrences in either the rectum or ileum. Half of the recurrences took place five or more years after surgery. Seven of the 12 patients with recurrences have had their anastomoses taken down. When this recurrence rate of 41% is compared with the recurrence of ileitis in patients after total colectomy and ileostomy for Crohn's disease of the colon, the incidence of recurrence is, as shown in many reports, not markedly dissimilar. Of the patients who develop a recurrence after ileorectal anastomosis, only about half will have to have their anastomoses taken down. In our study, 59% of the patients had no recurrence and another 20-5% had a recurrence but did not require 'take down' of the anastomosis. Thus, almost 80% of our patients at the time of this report have been able to lead a life unencumbered by an ileostomy, making ileorectal anastomosis for this disease a desirable procedure to consider in selected patients.

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.

Rectal biopsy as a prognostic guide in Crohn's colitis

In a retrospective study, 64 rectal biopsies from 27 patients with Crohn's disease limited to the large bowel have been reviewed using a semiquantitative grading of histological abnormality. The subsequent clinical course was assessed independently, and patients were included in one of four categories: (1) remaining asymptomatic; (2) showing continued moderate inflammatory activity; (3) requiring colectomy; and (4) dying as a direct result of colonic disease. Biopsies from group (4) showed a greater degree of histological abnormality than those in the other three groups. This difference was statistically significant for first biopsies ((4)-(1) p less than 0-05; (4)-(2) p less than 0-05). In any one patient the histological appearances were relatively constant from one biopsy to the next. The presence of either fissuring or ulceration suggested a poor prognosis.

Proctocolitis and Crohn's disease of the colon: a comparison of the clinical course

This study suggests that proctocolitis is an illness with an acute and potentially dangerous onset but which appears to become less severe after survival for one year, whereas Crohn's colitis tends to be a more chronic and progressive illness over several years with a greater need for surgical treatment and a greater tendency to anal complications.

An epidemiological study of regional enteritis in the Gloucester area

An epidemiological study has been made of regional enteritis in the Gloucester area during the period from 1 Jan., 1966, to 31 Dec., 1970. There were 19 cases in an average population of 253,000, giving an average incidence of new cases of 1.5 per 100,000 per year. There was a significant peak of cases in the 15–24 age-group. The incidence in men was slightly higher than in women. There was a family history of ulcerative colitis in 2 cases. There were 3 cases of regional enteritis of the large bowel only, all occurring in women. Extensive large- and small-bowel involvement occurred predominantly in the younger patients.

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.

Pathology of intestinal tuberculosis and its distinction from Crohn's disease

Intestinal lesions of 212 cases presenting with symptoms of intestinal obstruction were studied. Of these, 159 cases were diagnosed as tuberculosis and 10 as Crohn's disease. Forty-three cases could not be classified into any of these entities and are excluded from this account. The amount of chemotherapeutic drugs received by each patient preoperatively was recorded. Cases proved as tuberculosis at the first operation were put on antituberculosis chemotherapy. Thirteen of these cases were operated on a second time, and tissue reactions under the influence of chemotherapy were studied. Fresh diseased tissue was studied for acid-fast organisms by culture and animal inoculation.Morphological features of the tuberculosis group are described in detail. Although the cases were broadly classified into the ulcerative and ulcerohypertrophic varieties, a distinction was not always sharp and the two types of lesions were at times found to coexist. The macroscopic features presented a very wide range, and at times distinction from Crohn's disease, especially in the ulcerohypertrophic variety, was difficult. Microscopically, however, they could be distinguished without much difficulty. Caseation, although a characteristic feature of tuberculous granulomas may, albeit rarely, be absent. Granulomas which are characteristically confluent may be present only in the mesenteric lymph nodes. Acid-fast organisms are not grown consistently from diseased tissues; where grown, they are of human type. Reparative changes during chemotherapy are described in detail; these follow a non-specific pattern. In the group of Crohn's disease, transmural cracks and fissures were consistently observed in all cases. Distinguishing features between the two diseases are discussed in detail.

Recurrence of Crohn's disease after primary excisional surgery

The problems associated with recurrent Crohn's disease were examined in a series of 168 patients who had undergone primary resection for this condition at the General Infirmary at Leeds from 1939 to 1968 inclusive. The overall recurrence rate was 34.2%. The risk of recurrence was less in patients with involvement mainly of large bowel rather than small. It was also affected by the age of the patient, being greatest in children or adolescents, less in adults, and least in those over 60 years of age. Recurrent disease was most commonly found in the small bowel proximal to an anastomosis, and usually manifested itself either in the first year or two after surgery or some five to 15 years later. Patients with ;early' recurrence had a shorter history of symptoms at operation, and a graver outlook than those with ;late' recurrence. The status of recurrent cases was much better than might have been anticipated in so far as nearly 70% of them were considered at review to be in very good or good general health. Moreover the risk of further recurrence after a second or third operation was found to be no greater than after a first operation.

Acquired fistulae between the intestine and the vagina

Images

Colonic cancer and Crohn's disease

Four patients with both carcinoma and Crohn's disease of the colon are reported. Other cases in the world literature are summarized and the relationship between the two diseases is discussed. It is concluded that present evidence does not establish an increased risk of malignancy in colonic Crohn's disease.

Granulomatous colitis: recent observations

Images