Urologic complications in 200 patients with Crohn disease

The main urological complications of Crohn's disease are: vesico-intestinal fistula, ureteral obstruction, formation of urinary calculi and amyloidosis of the kidney. 200 patients suffering from Crohn's disease who had been treated in- or outpatient between 1973 and 1982 have been examined concerning urological complications. The frequency of complications was 14,5 per cent. Twenty patients developed fistulae, eleven had ureteral obstructions, two patients suffered from calculi and two from amyloidosis of the kidney. Due to this frequency a special urological diagnostic program is mandatory. A sonogram of the kidney and an i.v. urography should be made in case of pathological sonogram. This is as necessary as the control of kidney function and diagnosis of the urine. These specific urological complications are demonstrated in symptoms, diagnosis and therapy.     

Urologic complications in Crohn disease

The main urological complications of Crohn's disease are: vesico-intestinal fistula, ureteral obstruction, formation of urinary calculi and amyloidosis of the kidney. In the course of their illness nearly 4 to 10 per cent of patients with Crohn's disease suffer from these complications. The frequency of vesico-intestinal fistula is nearly 4 per cent; with great fluctuations, the frequency of ureteral obstruction is specified by 6 per cent. 10 per cent of all patients with Crohn's disease will suffer from secondary amyloidosis. In most cases the kidney is the organ of manifestation. In 5 per cent the formation of urinary calculi is complicating Crohn's disease. The specific complications are demonstrated in symptoms, diagnostic and therapy.     

Acute ureteral colic from an obstructing renal aspergilloma

Fungus balls of the renal collecting system are rarely of organisms other than Candida. A case of obstructing aspergilloma associated with acute ureteral colic is presented. The clinical features of this case are characteristic of renal aspergillomas in 10 additional cases described in the literature. Ten of the 11 patients were male. Each of the patients had an underlying disease that predisposed to fungal infection. Although all 11 patients were cured, diagnostic evaluation was often protracted as commoner causes of ureteral obstruction were excluded. Successful therapy required evacuation of the obstructing hyphal mass; open surgical procedures were necessary in five instances. Systemic amphotericin B should be reserved for patients with residual infection following removal of the fungus ball. This report emphasizes the need to consider aspergilloma in the differential diagnosis of acute ureteropelvic obstruction in the appropriate patient population.     

L’obstruction urétérale non lithiasique inaugurale d’une maladie de Crohn : une complication rare et méconnue

Noncalculous ureteral obstructions in Crohn??s disease are rare (3% in inflammatory bowel disease). They often are asymptomatic and unidentified. They are secondary to inflammation and fibrosis. Treatment could be medical or surgical. We report the case of a patient with non calculous ureteral obstruction revealing Crohn??s disease.     

Upper gastrointestinal Crohn's disease

Symptomatic gastroduodenal manifestations of Crohn's disease are rare, with less than 4% of patients being clinically symptomatic. Gastroduodenal involvement may, however, be found endoscopically in 20% and in up to 40% of cases histologically, most frequently as Helicobacter pylori-negative focal gastritis, usually in patients with concomitant distal ileal disease. In practice, the activity of concomitant distal Crohn's disease usually determines the indication for therapy, except in the presence of obstructive gastroduodenal symptoms. With the few data available, it seems correct to say that localized gastroduodenal disease should be treated with standard medical therapy used for more distal disease, with the exception of the galenic formulation of sulfasalazine and mesalazine with pH-dependent release. The presence of symptoms of obstruction needs aggressive therapy. If medical therapy with steroids and immunomodulatory drugs does not alleviate the symptoms, balloon dilation and surgery are the options to consider.     

Crohn's disease of the stomach with outlet obstruction: a case report and review of therapy

Crohn's disease of the stomach is an uncommon condition which often progresses to stenosis with associated gastric outlet obstruction. We describe a patient who obtained long-term relief of obstruction following a short course of corticosteroids and total parenteral nutrition, and we discuss the therapeutic options for gastroduodenal Crohn's disease.     

Is Crohn's disease caused by a mycobacterium? Comparisons with leprosy,tuberculosis, and Johne's disease

Although Crohn's disease is considered to be autoimmune in origin, there is increasing evidence that it may have an infectious cause. The most plausible candidate is Mycobacterium avium subspecies paratuberculosis (MAP). Intriguingly, Koch's postulates may have been fulfilled for MAP and Crohn's disease, even though they still have not been met for Mycobacterium leprae and leprosy. In animals MAP causes Johne's disease, a chronic wasting intestinal diarrhoeal disease evocative of Crohn's disease. Johne's disease occurs in wild and domesticated animals, including dairy herds. Viable MAP is found in human and cow milk, and is not reliably killed by standard pasteurisation. MAP is ubiquitous in the environment including in potable water. Since cell-wall-deficient MAP usually cannot be identified by Ziehl-Neelsen staining, identification of MAP in human beings requires culture or detection of MAP DNA or RNA. If infectious in origin, Crohn's disease should be curable with appropriate antibiotics. Many studies that argue against a causative role for MAP in Crohn's disease have used antibiotics that are inactive against MAP. However, trials that include macrolide antibiotics indicate that a cure for Crohn's disease is possible. The necessary length of therapy remains to be determined. Mycobacterial diseases have protean clinical manifestations, as does Crohn's disease. The necessity of stratifying Crohn's disease into two clinical manifestations (perforating and non-perforating) when interpreting the results of antibiotic therapy is discussed. Rational studies to evaluate appropriate therapies to cure Crohn's disease are proposed.     

Pseudopolyps in inflammatory bowel diseases: Have we learned enough?

Pseudopolyps are a well described entity in the literature and even though the exact pathogenesis of their formation is not completely understood, they are considered non-neoplastic lesions originating from the mucosa after repeated periods of inflammation and ulceration associated with excessive healing processes. Their occurrence is less common in Crohn's disease than in ulcerative colitis, and their overall prevalence ranges from 4% to 74%; moreover, they are found more often in colon but have been detected in other parts of the gastrointestinal tract as well. When their size exceeds the arbitrary point of 1.5 cm, they are classified as giant pseudopolyps. Clinical evaluation should differentiate the pseudopolyps from other polypoid lesions, such as the dysplasiaassociated mass or lesion, but this situation represents an ongoing clinical challenge. Pseudopolyps can provoke complications such as bleeding or obstruction, and their management includes medical therapy, endoscopy and surgery; however, no consensus exists about the optimal treatment approach. Patients with pseudopolyps are considered at intermediate risk for colorectal cancer and regular endoscopic monitoring is recommended. Through a review of the literature, we provide here a proposed classification of the characteristics of pseudopolyps.     

Crohn's Disease and Pancreatitis

Pancreatitis has rarely been reported as a complication of Crohn's disease. We report our experience with two cases of pancreatitis associated with Crohn's disease. In one, the pancreatitis occurred secondary to duodenal Crohn's disease involving the ampulla of Vater. Endoscopic retrograde pancreatography demonstrated involvement of the ampulla, with marked dilation and delayed drainage of the pancreatic duct, suggesting mechanical obstruction. In the second patient, Crohn's disease was localized to the ileum and colon. We conclude that duodenal Crohn's can cause pancreatitis, and this may, in some cases, be on an obstructive basis. In addition, non-duodenal Crohn's disease can be associated with pancreatitis as well. In a patient with a history of Crohn's disease presenting with an atypical exacerbation, pancreatitis should be considered.     

Crohn's disease as a contraindication to Kock pouch (continent ileostomy)

Crohn's disease is often described as a contraindication to the construction of a Kock pouch (KP), but a consensus opinion is less definite. One hundred consecutive patients with a KP were reviewed after a minimum follow-up time of 2 1/2 years. The 95 patients with inflammatory bowel disease were analyzed for serious complications. All eight patients in whom the diagnosis of Crohn's disease or inflammatory disease of indeterminate type was made suffered serious complications requiring resections of the pouch or continuing treatment. By contrast, of the 87 cases with ulcerative colitis, only 17 (20 percent) had complications, six of which were readily and simply corrected. Our findings suggest that Crohn's disease should continue to be regarded as a firm contraindication to the KP procedure. It should be actively sought out preoperatively, and it should be treated aggressively if it is discovered after surgery. If such a patient requires further surgery, the KP should be removed.     

Treatment of gastroduodenal Crohn's disease

Symptomatic gastroduodenal manifestations of Crohn's disease (CD) are rare, with less than 4% of patients being clinically symptomatic. Gastroduodenal involvement may, however, be found endoscopically in 20% and in up to 40% of cases histologically, most frequently as Helicobacter pylori-negative focal gastritis, usually in patients with concomitant distal ileal disease. In practice, the activity of concomitant distal CD usually determines the indication for therapy, except in the presence of obstructive gastroduodenal symptoms. With the few data available, it seems correct to say that localized gastroduodenal disease should be treated with standard medical therapy used for more distal disease, with the exception of sulfasalazine and mesalanine with pH-dependent release. Presence of symptoms of obstruction needs aggressive therapy. If medical therapy with steroids and immunomodulatory drugs does not alleviate the symptoms, balloon dilation and surgery are the options to consider.     

Gastrostomy placement in patients with Crohn's disease

Crohn's disease often involves the stomach, yet a permanent enterocutaneous fistula does not usually occur, after a percutaneous endoscopic gastrostomy is removed from a patient with Crohn's disease. This is because the factors that are related to the non-closure of a fistula are absent or have been treated (distal bowel obstruction, abdominal sepsis, undernutrition, poor gastric blood supply or abnormal serum levels of C-reactive protein and albumin). Gastric involvement in patients with Crohn's disease is common. Enterocutaneous fistulas from the stomach are rare. Percutaneous endoscopic gastrostomy (PEG) insertion and subsequent removal rarely cause problems in patients with Crohn's disease. Endoscopic removal of a PEG is advised in patients with Crohn's disease. Steroids may delay gastric adhesion to the anterior abdominal wall.     

Incidence and clinical significance of lactose malabsorption in ulcerative colitis and Crohn's disease

The incidence of lactose malabsorption was investigated in 85 patients with ulcerative colitis and 71 patients with Crohn's disease by means of lactose tolerance tests and disaccharidase determinations in small intestinal mucosa. Eight patients with ulcerative colitis (9%) and four with Crohn's disease (6%) had lactose malabsorption. A control group displayed a similar incidence. It is concluded that lactose malabsorption is not particularly common in ulcerative colitis and Crohn's disease. If it is present, its aetiology seems to be unrelated to the intestinal disease.Transitional lactose malabsorption was detected in two cases during a relapse of ulcerative colitis.Institution of a lactose-free (or lactose-poor) diet was an important supporting measure in seven patients who were unaware of their milk intolerance, in particular in two with ileostomy. Therefore, it is recommended that a lactose tolerance test should always be performed in patients with ulcerative colitis or Crohn's disease.Twenty-one patients with ulcerative colitis and nine with Crohn's disease, none of whom had lactose malabsorption, were placed on milk-free diets. A beneficial effect was noticed in five of the patients with ulcerative colitis, and in three of those with Crohn's disease. The mechanism is unknown.Evidence is presented that milk allergy is not responsible for the beneficial effect of a lactosefree diet in patients with associated lactose malabsorption.     

Obstructive uropathy secondary to sigmoid diverticulitis

From a review of the literature and detailed study of 16 cases, the authors believe that ureteral obstruction in diverticulitis is more common than is apparent from the literature. They suggest that urograms be performed preoperatively in patients destined to undergo intestinal surgery. Management of the intestinal disease need not be altered from that initially planned for treatment of diverticulitis except with the proviso that the retroperitoneum be examined for the presence of a fibrotic inflammatory reaction. If this is found, they suggest that ureterolysis of the involved ureter be performed to allow relief of this obstruction.     

Giant pseudopolyps presenting as colocolic intussusception in crohn's colitis

Bowel obstruction is a well-known complication of Crohn's disease and is usually a result of stricture formation. Intussusception due to giant pseudopolyps is a rare form of bowel obstruction even in Crohn's disease. These giant pseudopolyps rarely regress with medical management alone and often require surgical resection.     

Compared azathioprine efficacy in ulcerative colitis and in Crohn's disease

AIM: To compare the 6-month efficacy and tolerance of azathioprine in 68 patients with steroid-resistant or steroid-dependent chronic ulcerative colitis (n=30) or Crohn's disease (n=38).METHODS: Clinical remission was defined as a Crohn's Disease Activity Index<150 for Crohn's disease and number of non-bloody stools<=3/day for ulcerative colitis, associated with prednisone requirement<=10 mg/day.RESULTS: Seventy-three per cent of patients with ulcerative colitis had distal or left-sided colitis and 84% of patients with Crohn's disease had pancolitis. Azathioprine was discontinued early for side-effect in 8 (26.7%) patients with ulcerative colitis and in 8 (21.1%) patients with Crohn's disease (NS). In patients treated at least 6 months by azathioprine, clinical remission rates were 77.3% and 70% for chronic ulcerative colitis and Crohn's disease (NS). Complete corticosteroids weaning was obtained significantly more often in ulcerative colitis patients than in Crohn's disease patients (59.1% vs 30%; P<0.05).CONCLUSION: Azathioprine seems to be at least as effective and equally tolerated in steroid-resistant or steroid-dependent chronic ulcerative colitis or Crohn's disease patients.     

Fistulizing Crohn's disease

Fistulas are common in Crohn's disease. A population-based study has shown a cumulative risk of 33% after 10 years and 50% after 20 years. Perianal fistulas were the most common (54%). Medical therapy is the main option for perianal fistula once abscesses, if present, have been drained, and should include antibiotics (both ciprofloxacin and metronidazole) and immunomodulators. Infliximab should be reserved for refractory patients. Surgery is often necessary for internal fistulas.     

Fistulizing Crohn's disease

Fistulas are common in Crohn's disease. A population-based study has shown a cumulative risk of 33% after 10 years and 50% after 20 years. Perianal fistulas were the most common (54%). Medical therapy is the main option for perianal fistula once abscesses, if present, have been drained, and should include antibiotics (both ciprofloxacin and metronidazole) and immunomodulators. Infliximab should be reserved for refractory patients. Surgery is often necessary for internal fistulas.     

Indications for surgery in Crohn's disease: analysis of 500 cases.

Data for 500 patients with Crohn's disease who underwent operations were analyzed (316 patients, 1966 to 1969; 184 patients, 1972 to 1973) by comparison of various anatomic disease locations (clinical pattern): (1) ileocolic, 225 patients; (2) small intestinal, 130 patients; (3) colonic, 127 patients; (4) anorectal, 18 patients. Indications for surgery were tabulated and compared using statistical analysis for the three large patterns. For patients with ileocolic Crohn's disease, the primary surgical indications were internal fistula and abscess, 44%, intestinal obstruction, 35%, and perianal disease, 12%. For patients with Crohn's disease of the small intestine, the primary surgical indications were intestinal obstruction, 55%, and intestinal fistula and abscess, 32%. Patients with colonic Crohn's disease had a significantly more diverse surgical indication, with poor response to medical therapy, 26%, internal fistula and abscess, 23%, toxic megacolon, 20%, and perianal disease, 19%. These values were highly statistically significant (P less than 0.0001) in all instances but one. This study demonstrates that statistically significant differences occur in the surgical indication depending on the location of Crohn's disease. Patients with ileocolic, small intestinal, and colonic involvement have striking differences in clinical course. It is concluded that Crohn's disease is not a homogeneous entity, but should be recognized as having a varying course depending on clinical pattern.     

Sex-specific risks for pediatric onset among patients with Crohn's disease.

BACKGROUND & AIMS: Increases in the incidence of pediatric Crohn's disease might reflect increases in incidence for onset at all ages or diagnostic improvement. Alternatively, there might be etiologic differences between adult and pediatric-onset disease with different risks for pediatric disease. Differences in sex ratio between adult and pediatric disease suggest etiologic differences might exist and also suggest differences in sex-specific susceptibility during childhood. This study seeks to identify whether factors previously associated with overall risk of Crohn's disease (number of siblings and maternal age) are associated with pediatric as opposed to adult onset among patients with Crohn's disease and whether these associations vary by sex. METHODS: A nested case-control study of patients with Crohn's disease was designed to compare pediatric with adult-onset disease. The participants were all patients with Crohn's disease in the Swedish Inpatient Register born between 1960 and 1998; 46.6% of the 4826 patients were male. RESULTS: A notable association between mother's age at pregnancy and pediatric Crohn's disease was observed in female but not male patients. Compared with those whose mothers were younger than 21 years, female patients with older mothers, coded into ordered 5-year age categories, were at a higher risk of pediatric disease with adjusted odds ratios (95% confidence intervals) of 1.42 (0.85-2.37), 2.08 (1.19-3.66), 3.50 (1.83-6.69), 3.02 (1.35-6.75), and 12.64 (3.63-43.98). No statistically significant independent associations were observed for father's age or number of siblings. CONCLUSIONS: Females might be more susceptible or more often exposed to factors associated with older maternal age at pregnancy that increase their risk of pediatric-onset Crohn's disease.