Crohn's disease. A clinical study based on 186 patients

Radiologic appearance of recurrent ileal Crohn disease

BACKGROUND

Postoperative recurrence of Crohn disease is a common problem. It has been assumed that the radiologic patterns are similar in de novo and recurrent ileal disease, but there has been little in the literature to actually confirm this belief.

METHODS

We retrospectively reviewed the small bowel examinations of 105 consecutive patients with a proven diagnosis of Crohn disease: a control group of 47 patients with no prior surgery and a postoperative group of 58 patients with resections. Of the latter, 22 had ileocecal or ileocolonic resections and 36 patients had ileocecal or ileocolonic and extensive enteric resections. We examined the disease sites and compared the disease patterns in both groups.

RESULTS

Fifty-six of 58 (97%) postoperative patients had anastomotic recurrences with proximal extension from 3 to 25 cm, with a mean of 10.5 cm; none showed distal disease extension. Two (3%) had enteric recurrences with neoterminal ileal sparing. There were no statistically significant differences in the length of distal/terminal ileal disease and the frequency of skip lesions in de novo and recurrent disease. There were lower frequencies of mucosal thickening, ulceration/ulceronodular mucosa, sacculation, loop separation, sinuses, and masses and a higher frequency of strictures in recurrent disease than in de novo disease. There was also a lower frequency of ulceration or ulceronodular mucosa after extensive resection than after limited resection.

CONCLUSION

Postoperative patients with ileal Crohn disease show a marked preponderance for anastomotic recurrence with proximal disease extension. There are significant differences in disease patterns in patients with de novo and recurrent disease.

Diagnosis and misdiagnosis of inflammatory bowel disease

Several diseases can mimic IBD clinically, but careful and repeated evaluations, if necessary, will dramatically decrease the likelihood of misdiagnosis. A careful consideration of patient's clinical, radiographic, endoscopic, and histopathologic features will establish the correct diagnosis in the majority of cases.

Inflammatory bowel disease

Although ulcerative colitis and Crohn's disease are relatively uncommon disorders, most primary care practices include a number of individuals with these diagnoses. Much of the initial evaluation and long-term care of these patients is managed or coordinated by their primary care physicians. A familiarity with current principles of diagnosis and treatment is essential. Ulcerative colitis and Crohn's disease are related, immunologically mediated disorders of unknown cause. Both are characterized by chronic relapsing courses, frequent need for surgical intervention, and increased colorectal cancer risk. Significant differences are seen between these two inflammatory bowel disease syndromes, in their histopathologic features, clinical manifestations, and response to treatment. This review focuses on the colorectal manifestations of inflammatory bowel disease, emphasizing clinical presentation, approach to diagnosis, medical and surgical management, and long-term prognosis.

Effect of resection margins on the recurrence of Crohn's disease in the small bowel. A randomized controlled trial

OBJECTIVE

The authors assess the effect of surgical margin width on recurrence rates after intestinal resection of Crohn's Disease (CD).

BACKGROUND

The optimal width of margins when resecting DC of the small bowel is controversial. Most studies have been retrospective and have had conflicting results.

METHODS

Patients undergoing ileocolic resection for CD (N = 152) were randomly assigned to two groups in which the proximal line of resection was 2 cm (limited resection) or 12 cm (extended resection) from the macroscopically involved area. Patients also were classified by whether the margin of resection was microscopically normal (category 1), contained nonspecific changes (category 2), were suggestive but not diagnostic for CD (category 3), or were diagnostic for CD (category 4). Recurrence was defined as reoperation for recurrent preanastomotic disease.

RESULTS

Data were collected on 131 patients. Median follow-up time was 55.7 months. Disease recurred in 29 patients: 25% of patients in the limited resection group and 18% of patients in the extended resection group. In the 90 patients in category 1 with normal tissue, recurrence occurred in 16, whereas in the 41 patients with some degree of microscopic involvement, recurrence occurred in 13. Recurrence rates were 36% in category 2, 39% in category 3, and 21% in category 4. No group differences were statistically at the 0.01 level.

CONCLUSION

Recurrence of CD is unaffected by the width of the margin of resection from macroscopically involved bowel. Recurrence rates also do not increase when microscopic CD is present at the resection margins. Therefore, extensive resection margins are unnecessary.

Factors influencing recurrence in Crohn's disease. An analysis of a consecutive series of 353 patients treated with primary surgery

PURPOSE

This study was undertaken to investigate the factors that influenced the risk of symptomatic recurrence in patients with Crohn's disease who were treated with primary resective surgery.

METHODS

Data regarding age, gender, time from diagnosis to surgery, medication, preoperative infectious complications, laboratory values, emergency/elective surgery, location and extent of disease, and resection margins were analyzed in relation to recurrence in 353 patients who were undergoing a "curative" resection in 1969 to 1986.

RESULTS

Univariate analyses showed a higher risk of recurrence in women with ileal and ileocolonic disease than in men (P < 0.05), in patients with ileocolonic disease compared with those with isolated ileal disease (P < 0.05), and in ileal disease patients with an increased disease extent (P < 0.05). In a multivariate analysis performed on patients with ileal disease, increased disease extent, limited resection on the colonic side, and referral from other hospitals were three independent variables that indicated an increased risk of recurrence (P < 0.05). Length of disease-free resection margins did not influence the risk of recurrence either in univariate or in multivariate analysis (P > 0.05).

CONCLUSIONS

Disease extent has prognostic value regarding the risk of symptomatic recurrence in Crohn's disease, whereas the length of resection margins does not influence the risk of relapse. These results favor a conservative approach, particularly in patients with extensive disease.

Leukocytapheresis therapy, performed with leukocyte removal filter, for inflammatory bowel disease

Leukocytapheresis (LCAP), performed with a leukocyte removal filter, was administered five times, at 1-week intervals, for 5 weeks of intensive therapy and five times, at approximately 1-month intervals, for approximately 5 months of maintenance therapy, to 13 patients with inflammatory bowel disease (IBD) diagnosed as ulcerative colitis (UC) in 8 and Crohn's disease (CD) in 5. Clinical and blood examinations showed no side effects in any of the patients. During the intensive therapy, excellent or moderate clinical response was recognized in 11 of the 13 patients (84.6%), of whom 6 had a dramatic response; the excellent or moderate clinical response continued throughout the maintenance therapy in 8 of the patients (61.5%). Flow cytometry showed that the patients who had improved generally had high values for percentages of HLADR+, HLADR+CD3+, and HLADR+CD8+ cells before the first LCAP, and that these values and the C-reactive protein levels and erythrocyte sedimentation rates had decreased to the normal range by the end of both intensive and maintenance therapy. In the patients who showed poor response, in contrast, all the above values had been at or near normal before the initial LCAP administration. The clinical improvement in the absence of any additional medical treatment suggests that LCAP has the capacity to influence the causal mechanism(s) of IBD and that IBD is strongly associated with the cell-mediated immune response.

Life-threatening hemorrhage and exsanguination from Crohn's disease. Report of four cases

PURPOSE AND METHODS

From 1979 through 1991, four patients of 631 admissions (0.6 percent) for Crohn's disease in Erie, Pennsylvania, presented with life-threatening gastrointestinal hemorrhage. These and 34 similar cases from the medical literature were reviewed to provide a composite of those at risk and elucidate appropriate diagnostic and therapeutic maneuvers.

RESULTS

The study revealed a preponderance of young men (2:1 ratio) with an average age of 35 (range, 14-89) years, the majority of whom had known Crohn's disease (60 percent) for an average of 4.6 (range, 0-18) years. The site of bleeding resembled the general distribution for Crohn's disease, with small bowel disease predominating (66 percent involved the ileum). The five cases of exsanguination (13 percent of the total) were all men with known Crohn's disease (average, 5.8 years) involving the ileum alone or in part. Mesenteric arteriography was positive in 17 patients, providing precise preoperative localization resulting in no mortality in this group. Excluding those who presented with exsanguination, surgery was necessary to cease hemorrhage in 91 percent (30/33) of patients. Ileocolectomy was the most frequently performed procedure (53 percent). In follow-up, only one patient required further surgical resection for recurrent bleeding (3.5 percent), and two other patients (7 percent) required further therapy for nonhemorrhagic recurrence.

CONCLUSION

Crohn's disease may be responsible for life-threatening gastrointestinal hemorrhage and even exsanguination. Many of the characteristics of these patients resemble the general Crohn's disease population. Surgical resection provides excellent palliation. A long-term benign course can be expected in this subgroup of Crohn's disease patients.

Multiple vitamin status in Crohn's disease. Correlation with disease activity

We measured serum, blood, or red cell concentrations of various vitamins in 24 patients with Crohn's disease who had been free from any nutritional treatment, and compared them with those in 24 healthy controls. Twelve of the patients were affected in the small bowel only, two in the large bowel only, and the remaining 10 in both the small and large bowel. The fat-soluble vitamins A and E were significantly decreased in patients with Crohn's disease compared to controls. Among the water-soluble vitamins, vitamins B1, B2 and B6 and folic acid were more depleted in patients with Crohn's disease than in the controls, whereas vitamins B12 and C, nicotinic acid, and biotin were not different between the two groups, and pantothenic acid was increased in patients with Crohn's disease. In addition, vitamin B2 and nicotinic acid showed a negative correlation with the Crohn's disease activity index. These findings suggest that there is a variety of vitamin deficiencies in Crohn's disease prior to treatment and also that concentrations of some vitamins, such as vitamin B2 and nicotinic acid, may reflect the severity of the disease.

Risk of recurrence and reoperation after resection for ileocolic Crohn's disease

To evaluate possible risk factors for recurrence after primary resection of ileocolic Crohn's disease, the clinical course of 48 consecutive patients operated on over a 27-year period were reviewed. Median follow-up was 10 years (range, 3-27 years). The probability of not having a recurrence and the probability of not undergoing a second resection were 0.476 (+/- 0.191, 95% confidence limits) and 0.701 (+/- 0.180), respectively, after 10 years. None of the possible risk factors examined--sex, age at the primary resection, length of preoperative history, length of bowel involvement, failure of preoperative medical treatment, and residual microscopic disease at resections lines--significantly influenced the risk of recurrent disease (P greater than 0.05, log-rank test); however, there was a trend towards a higher risk of recurrence for the patients who had received medical treatment preoperatively. In the present study it was not possible to identify any factors that influenced the risk of recurrence.

The influence of zinc status and malnutrition on immunological function in Crohn's disease

Cellular immunity is likely to be important in the pathogenesis of Crohn's disease; whether it is abnormal is not clear. The heterogeneity of patients with Crohn's disease probably underlies the disparity of reports, but attempts to determine which clinical features influence cellular immunity have been largely unsuccessful. This is probably caused by the omission of nutritional status as a potential factor, even though zinc deficiency has frequently been linked with abnormal immunity. Therefore, a detailed study of nutritional and tissue zinc status, nonspecific cellular immunity, and a measure of phagocytic function was performed in 32 patients with Crohn's disease and in a control group of 18 normal subjects and 12 patients with anorexia nervosa. Fourteen patients with Crohn's disease, all patients with anorexia nervosa, but none of the normal controls were malnourished. Peripheral blood lymphocyte population levels were normal in patients with Crohn's disease and in normal controls, but there was a small decrease in the levels of patients with anorexia nervosa. In vivo delayed hypersensitivity skin test responses were profoundly depressed in patients with anorexia nervosa and decreased in patients with Crohn's disease who were malnourished or receiving systemic glucocorticoids. In vitro lymphocyte transformation was reduced in malnourished patients with Crohn's disease, but there were only minor changes in patients with anorexia nervosa. There were alterations of in vitro immunoregulation in Crohn's disease, but they were not responsible for the abnormal lymphocyte transformation responses in malnourished patients. In vitro phagocytic function was reduced in patients with active Crohn's disease. These findings suggest that depressed in vivo and in vitro cellular immunity in malnourished patients with Crohn's disease is caused by a qualitative lymphocyte defect and that depressed in vivo but normal in vitro cellular immunity in anorexia nervosa is caused by a quantitative defect. Thus, malnutrition in Crohn's disease resembles kwashiorkor; in anorexia nervosa, it resembles marasmus. Tissue zinc status was mostly normal in Crohn's disease and anorexia nervosa, and zinc deficiency was not responsible for depressed nonspecific cellular immunity in either condition.

Severe gastrointestinal hemorrhage in Crohn's disease

Twenty-one of fifteen hundred twenty-six patients with Crohn's disease (CD) treated at The Mount Sinai Hospital between 1960 and 1986 developed severe gastrointestinal hemorrhage. There were 26 separate episodes of severe hemorrhage: 17 patients bled only once, three bled twice and one bled three times. The frequency of bleeding was significantly higher among patients with colonic involvement (17 of 929; 1.9%) than among those with small bowel disease alone (4 of 597; 0.7%) (p less than 0.001). Twelve patients required surgery on 13 occasions, which involved colon resection in all but one case. Eleven of these patients underwent surgery during their first hemorrhagic episodes, and 1 of 11 had a second operation for recurrent bleeding; the 12th patient, whose first hemorrhage had been treated medically, had surgery during a repeated episode of hemorrhage. The precise bleeding points could be located in only 2 of the 26 bleeding episodes, both at the ileocecal area. Three patients died, of whom two had not undergone surgery when they had bled a few weeks earlier. Primary bleeding episodes subsided without surgery in 10 of 21 cases, but 3 of these 10 patients (30%) rebled massively. By contrast primary excisional surgery was followed by recurrent hemorrhage in only 1 of 11 cases (9%). These differences in mortality and in recurrent bleeding rates, although not statistically significant, seem to favor removal of diseased bowel at the time of the first episode of massive hemorrhage.

Indiscretion enteritis. A Rabelaisian syndrome

A 76-year-old man had small bowel obstruction and organic small bowel disease following a series of bizarre massive gustatory insults that involved food, medications, and mega-mineral-vitamin supplements. Intestinal obstruction required partial small bowel resection. The dietary indiscretions resulted in severe enteritis (indiscretion enteritis). The sequence has been termed a Rabelaisian syndrome after the great French writer and physician, Francois Rabelais, who vividly described bizarre gustatory habits. Gut injury may result from unwise oral intake of various foods and mineral supplements.

Crohn's disease. A long-term study of the clinical course in 186 patients

A series of 186 patients treated for Crohn's disease during the period 1956 to 1968 has been followed up in 1970, 1975, and now in 1983. Among 173 patients operated on there were 89 recurrences (52%). After a follow-up time greater than 14 years (mean, 18 years) 'radical' resections at the first operation gave a lower recurrence rate (31%), fewer reoperations, and a better quality of life compared with non-'radical' resections (recurrence rate, 83%). The quality of life estimated for all patients alive in 1983, 152 patients, was good in 89%; 8.6% had moderate subjective symptoms, and 2.6% had pronounced subjective symptoms. With an increasing follow-up time there was no decrease in the patients' quality of life. Ileorectal anastomosis did not give very good results; proctocolectomy and ileostomy, however, gave good results. Regular investigation of all patients is of vital importance to give them a good quality of life.

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.

Nutritional disturbances in Crohn's disease

A wide range of nutritional disturbances may be found in patients with Crohn's disease. As more sophisticated tests become available to measure vitamin and trace element deficiencies, so these are being recognized as complications of Crohn's disease. It is important to recognize nutritional deficiencies at an early stage and initiate appropriate treatment. Otherwise many patients, experiencing what can be a chronic and debilitating illness, may suffer unnecessarily from the consequences of deprivation of vital nutrients.

Increasing incidence of Crohn's disease

Reports in the literature have shown an increased incidence of Crohn's disease. The incidence in Spokane, Washington, was calculated on the basis of number of first hospitalizations for that diagnosis at all private hospitals within the city. The incidence in 1971 was 5.9 per 100,000 population and increased to 8.8 per 100,000 population in 1981, which is the highest incidence reported in the literature. The number of admissions and operations for Crohn's disease increased threefold in that same time interval. Possible pitfalls of such incidence studies have been discussed. We believe our results indicate a true and continuing increase in the incidence of Crohn's disease.

Controlled trial of supplemented oral nutrition in Crohn's disease

28 malnourished patients with Crohn's disease completed a controlled cross-over study to examine the effect of a low-residue liquid supplement on nutrition and disease activity. Patients spent two months on an ordinary diet (control period) and for two months took the nutritional supplement in addition (treatment period): the order of treatment and control periods was randomised. All anthropometric measurements, serum proteins, creatinine height index, and circulating T lymphocyte numbers increased significantly in the treatment period, while serum orosomucoid levels dropped significantly, suggesting that disease activity was reduced. The benefits were apparently due to the higher calorie intake with the enteral supplement. The results show that enteral supplementation can be managed successfully at home and may produce improvements in nutrition and disease activity.

Parenteral nutrition in Crohn's disease

A retrospective study of 50 consecutive patients admitted to hospital with Crohn's disease has been undertaken in order to assess the place of parenteral nutrition in our management of this disease. Following treatment, median weight, hemoglobin, and plasma albumin were the same in three treatment groups--parenteral nutrition (12), low-residue diet (9), and normal diet (29). Of 13 courses of parenteral nutrition used in 12 patients, 10 were for periods of less than 14 days (median four days). Most patients with nutritional problems associated with Crohn's disease can be treated successfully by one or other form of enteral nutrition. Parenteral nutrition, if required, is usually only necessary for periods of less than two weeks, to support patients over a critical period in their illness. Occasionally prolonged parenteral nutrition is required for short-bowel syndrome or advanced fistulous disease. In these cases, training the patient to infuse himself with nutrients at home has much to recommend it.

Radiographic appearances in Crohn's disease. IV. The new distal ileum after surgery

Postoperative films of 150 patients operated upon for Crohn's disease were reviewed with regard to postoperative abnormalities in the new distal ileum. The lesions were always located in the most aboral part of the ileum. In patients with persistent colonic disease the ileal lesions were apparently the result of a spread of colonic lesions. In many of the remaining patients there was strong evidence that recurrent disease was representative of persistent disease.

Is the ascending colon dispensable in resection for Crohn's disease?

Resection for chronic ileocaecal Crohn's disease may be conservative with ileo-ascending-colon anastomosis, or be extended to standard right hemicolectomy. The two operations have been compared to determine whether preservation of the ascending colon is advantageous. Stool frequency, consistency and weight were similar after the two operations. A slower stool transit time was the only clinical difference associated with preservation of the ascending colon. An adaptable and patient-acceptable technique for domicillary collection of stools is described.

Superficial lesions in Crohn's disease of the small bowel

Double-contrast examinations of the small bowel were compared with operative specimens obtained within 4 weeks after X-ray evaluation of 20 patients with Crohn's disease. Objective evidence of superficial lesions was submucosal edema and superficial ulcerations observed in the operative specimens. Edema was seen radiographically in 18 of 20 patients. Superficial ulcerations were seen radiographically in 8 of 14 patients. These ulcerations were either single with edematous edges or smaller, multiple, and more uniformly spread. The diagnosis demands a high-quality technique and even then the diagnostic accuracy is not always optimal.

Crohn's disease. Recurrence after surgical treatment

A series of 76 patients who have undergone surgical treatment for Crohn's disease is presented. In 14 of the patients surgery was performed for recurrence after previous resection. In total, 91 intestinal resections and one bypass--operation were carried out. Postoperative mortality comprised 4 patients (5.3%), and there were 4 late deaths. Sixty-six patients were followed up for periods ranging from 2 to 11 years, with a median of 4.0 years. Recurrence rates and reoperation rates were determined by actuarial analyses. The yearly recurrence rate seemed constant during the observation period, averaging 15.2%, and the cumulative recurrence rate was thus 77% after 9 years. The reoperation rate also seemed to be constant, and on the average 5.5% per year, and the cumulative reoperation per cent after 9 years was 45. There was no significant difference between cumulative recurrence rates after primary operations and after operations for recurrence. There was a significantly higher risk of relapse during the first year after non-radical excision of the diseased part of the gut than after radical excision. The majority of the patients were in good general condition at time of review; only 3 patients suffered from marked symptoms with reduced working capacity.

Hepatic and gastrointestinal disorders in pregnancy

The presentation, nonradiologic diagnostic evaluation, and course (including complications and outcome) of gastrointestinal disorders in pregnancy are not substantially different than for the nonpregnant patient. The possible exception is the higher mortality for pancreatitis when it occurs during pregnancy. With the exception of nausea/vomiting and hyperemesis gravidarum, there does not appear to be a gastrointestinal tract disorder that is peculiar to the pregnant state. Hepatic disorders are somewhat different in that the excretory defect-pruritus gravidarum-cholestatic jaundice spectrum and perhaps part of what presents as acute hepatic failure are intimately associated with pregnancy and have an onset and course that are tied to the gestational period. Otherwise, hepatic diseases that occur during pregnancy share the characteristic of gastrointestinal diseases, that their manifestations are not clearly different from the nonpregnant state. As is true for the diagnostic approach to all medical diseases that occur during pregnancy, radiographic procedures are prohibited. Furthermore, therapy must be reconsidered with concern for its effect on the fetus. This leads to elimination of many or all measures used for purely symptomatic or nonspecific benefit. If no harm or potential harm will accrue for the fetus, therapy for hepatic and gastrointestinal disorders preceeds in pregnancy very much as it does in the nongravid individual.

Crohn's disease. A long-term study of the clinical course in 186 patients

A series of 186 patients with Crohn's disease treated during the period 1956--1968 was followed up. During the follow-up period about 95% of the patients had undergone resection or by-pass surgery. The patients operated on between 1956--1968 were followed up with reference to recurrence rate. The mean observation time was 10.5 years. The recurrence rate after resection was 51%. "Radical" resection gave 29% recurrences. "Non-radical" resection gave 84% recurrences. Patients who had undergone a primary "radical" resection needed fewer re-operations, had fewer recurrences and a better "quality of life" than patients with a "non-radical" first operation. The total mortality in operations or due to complications of Crohn's disease in the series was 5.4%. The mortality in connection with operations was 3.4%. The general health of the patients examined in 1975 (165 patients) was estimated; 87% were in very good general health, 9.1% had moderate subjective symptoms, and 3.6% had pronounced subjective symptoms.

The protean manifestations of Crohn's disease

Crohn's disease is a perplexing disease with a high rate of morbidity and complications. The incidence appears to be increasing. The cause is unknown, and response to medical therapy has been disappointing. Diagnosis may be very difficult and often is delayed. A high proportion of patients eventually require surgery, and an appreciable percentage will have recurrence of disease afterward. The prognosis in terms of responsiveness to medical therapy is believed to be poorer than the prognosis of ulcerative colitis. A national cooperative study to assess drug therapy prospectively is under way.

Malnutrition and malabsorption in Crohn's disease with reference to the effect of surgery

Sixty-three patients with Crohn's disease showed a high incidence of nutritional deficiencies as judged by laboratory tests. Malabsorption of fat (33 per cent) and vitamin B12 (60 per cent) was not sufficiently severe to account for the malnutrition. Malnutrition was especially severe in unoperated patients with active disease, whereas malabsorption was prominent in patients with recurrent disease after resection although they had less active disease and less severe nutritional deficits. Surgery should not be withheld from a malnourished patient for fear of inducing further malnutrition; excision of toxic inflammatory disease will not only improve the immediate outlook but will also reduce the severity of further recurrences. Xylose-excretion tests give a spurious impression of malabsorption in Crohn's disease, possibly as a result of occult renal impairment, and should be abandoned.