Crohn's disease, with special reference to surgical management

Effect of ulcerative colitis in the bursting strength of colonic anastomoses in rats

Inflammatory bowel disease may have a deleterious effect on bowel healing, but its role is difficult to demonstrate in clinical practice because of the association of multiple factors. An experiment was conducted in rats. They were divided into two groups: group I, a model of acetic acid induced colitis, and group II, the control group. Both groups underwent a rectal resection and primary anastomosis. On postoperative day 7, the bursting strength of the anastomosis was evaluated. There were 44 rats in group I and 38 in group II. In 91% of group I rats there were histopathological changes compatible with inflammatory bowel disease (IBD). Mean bursting pressure was significantly reduced in rats with acetic-acid induced IBD (142.18 +/- 18.22 mm Hg in group I, and 208.85 +/- 14.8 mm Hg in group II; p < .05). These results suggest the deleterious effect of IBD on bowel healing.

Acute and late radiotherapy toxicity in patients with inflammatory bowel disease

PURPOSE

To evaluate the incidence of gastrointestinal complications in patients with inflammatory bowel disease (IBD) receiving radiotherapy (RT) and to identify possibly avoidable factors associated with these complications.

METHODS AND MATERIALS

Twenty-four patients were identified and their records reviewed; all had a history of IBD before receiving RT to fields encompassing some portion of the gastrointestinal tract (Crohn's disease) or to the abdomen or pelvis (ulcerative colitis or IBD not otherwise specified).

RESULTS

Five of 24 patients (21%) experienced Grade > or =3 acute gastrointestinal toxicity; all 5 received concurrent chemotherapy. Two of 24 patients (8%) experienced Grade > or =3 late gastrointestinal toxicity. There were no significant correlations between complications and IBD type, prior IBD-related surgery, use of medications for IBD, or status of IBD.

CONCLUSION

Patients with IBD may have an increased risk for severe acute RT-related gastrointestinal complications that is more modest than generally perceived, because all patients who had Grade > or =3 acute complications in this study had received concurrent chemotherapy (p = 0.04). Further study is needed to assess this risk, as well as the impact of RT on these patients' future gastrointestinal morbidity.

Crohn's disease and the mycobacterioses: a review and comparison of two disease entities

Crohn's disease is a chronic granulomatous ileocolitis, of unknown etiology, which generally affects the patient during the prime of life. Medical treatment is supportive at best, and patients afflicted with this disorder generally live with chronic pain, in and out of hospitals, throughout their lives. The disease bears the name of the investigator who convincingly distinguished this disease from intestinal tuberculosis in 1932. This distinction was not universally accepted, and the notion of a mycobacterial etiology has never been fully dismissed. Nevertheless, it was 46 years after the distinction of Crohn's disease and intestinal tuberculosis before research attempting to reassociate mycobacteria and Crohn's disease was published. Recently, there has been a surge of interest in the possible association of mycobacteria and Crohn's disease due largely to the isolation of genetically identical pathogenic Mycobacterium paratuberculosis from several patients with Crohn's disease in the United States, the Netherlands, Australia, and France. These pathogenic organisms have been isolated from only a few patients, and direct evidence for their involvement in the disease process is not clear; however, M. paratuberculosis is an obligate intracellular organism and strict pathogen, which strongly suggests some etiologic role. Immunologic evidence of a mycobacterial etiology, as assessed by humoral immune determinations, has been conflicting, but evaluation of the more relevant cellular immunity has not been performed. Data from histochemical searches for mycobacteria in Crohn's disease tissues have been equally conflicting, with acid-fast bacilli detected in 0 to 35% of patients. Animal model studies have demonstrated the pathogenic potential of isolates as well as elucidated the complexity of mycobacterial-intestinal interactions. Treatment of Crohn's disease patients with antimycobacterial agent has not been fully assessed, although case reports suggest efficacy. The similarities in the pathology, epidemiology, and chemotherapy of Crohn's disease and the mycobacterioses are discussed. The issue is fraught with controversy, and the data generated on the association of mycobacteria and Crohn's disease are in their infantile stages so that a general conclusion on the legitimacy of this association cannot be made. While no firm evidence clearly implicates mycobacteria as an etiologic agent of Crohn's disease, the notion is supported by suggestive and circumstantial evidence and a remarkable similarity of Crohn's disease to known mycobacterial diseases.

Recurrence rate after surgical treatment of Crohn's disease

In an unselected series of 207 consecutive patients with Crohn's disease diagnosed between 1958 and 1974, 170 underwent a resection of all the macroscopically involved bowel ('radically' resected). Two patients died during the first postoperative month. The crude recurrence rate for the surviving 168 patients was 49%. The cumulative recurrence rate, calculated by the actuarial method, was 53% at 15 years. Age, sex, length of preoperative disease history, localization of the lesions in the bowel, and primary surgical procedures performed had no influence on the recurrence rate. However, the histopathological appearance of the resection margins seemed to influence the prognosis, since the presence of ulcers and/or granulomas was correlated with a significantly increased recurrence rate.

The long-term outcome of restorative operation in Crohn's disease: influence of location, prognostic factors and surgical guidelines

The course of all 113 patients with Crohn's disease whose initial procedure involved an anastomosis operated upon from 1942 to 1972 was followed through 1980. The calculated cumulative 30-year total mortality was 23.4%, 16.7% disease-related. The cumulative recurrence rate was 29% at five years, 52% at ten years, 64% at 15 years and 84% at 25 years, with no important differences between disease locations and types of operation. Sex, age, duration, granulomas, enteral or perirectal fistulas and length of the resection, the disease, and the proximal resection margin had no significant influence on the rates of development of recurrent disease or on functional outcome. By far the most common site of recurrence was the neo-terminal ileum, but in ileocolitis compared with ileitis, recurrence was 5.2 times more likely (p = 0.0001) to involve the adjacent or remote colon as well. Moreover, only 1/63 ileitis patients eventually required ileostomy, whereas 15/47 patients with ileocolitis or colitis ultimately required this procedure (p less than 0.001). The current status of the patients was excellent or good in 64% and unwell or dead related in 24%. Urolithiasis developed in 19%.

Short-term course and prognosis of Crohn's disease

An analysis is presented of the course and outcome of the initial referred attack in a group of 332 patients with Crohn's disease treated at the General Infirmary at Leeds from 1939 to 1968 inclusive. A further 50 cases were excluded on the basis of insufficient diagnostic evidence: usually such patients had acute terminal ileitis. Only 5% of patients achieved full remission on conservative management, and most eventually came to surgery. The overall fatality rate was some 3.3% and this was affected chiefly by the severity of attack and the age of the patient. The severity of attack was classified as mild, moderate, or severe according to a system which took into account factors such as bowel habit, rectal bleeding, abdominal pain, pulse rate, temperature, haemoglobin, and weight. In attacks graded as ;mild', no deaths occurred; in those graded ;severe' the fatality rate was 8.8%. Similarly, whilst no patient under 20 years of age died, the fatality rate in the over 60s was some 14.8%. Further comparison between the present group of 332 patients and an earlier series of 204 patients suffering from ulcerative colitis (Watts, de Dombal, Watkinson, and Goligher, 1966a) shows considerable differences in the course and prognosis of the two diseases. In particular 70% of patients with ulcerative colitis achieved remission on conservative management alone whereas only 5% of Crohn's disease patients did so. These differences, and in particular the poor response to conservative therapy, are discussed, together with their implications for management.