Crohn''s Disease of the Colon

In a group of 160 patients with Crohn's disease involving the colon, there were seven patients with toxic dilatation, four with granulomatous colitis and three with ileocolitis, all successfully treated without mortality. This complications is more common than previously recognized in Crohn's colitis. In Crohn's disease, toxic dilatation is less likely to proceed to perforation of the bowel, because of the nature of the pathology and is more likely to respond to conservative measures: intubation, with decompression, corticotropin, steroids and high-dose antibiotic administration. Although patients do recover from this life-threatening complication with conservative management, the majority of patients, if not all, will ultimately come to surgical excision of the colon. If surgery is mandatory, it should be carried out early, rather than late, in the patient who is failing to respond to medical therapy, certainly before the development of perforation, massive hemorrhage, or gram negative sepsis with shock. The surgical therapy will depend upon the state of the bowel at laparotomy. Thus, an intact bowel in a young patient, would favor subtotal colectomy or proctocolectomy; a sealed perforation, a diverting ileostomy with skin level colostomy decompression as suggested by Turnbull and a free perforation, the minimum adequate procedure which will tide the patient over the early postoperative period. Diverting ileostomy alone has been effective in two of our patients but should be avoided in ulcerative colitis. The critically ill patient with the ominous finding of "disintegrating colitis" and multiple leaks, will require nothing less than total radical excision of the diseased bowel in the hope of immediate salvage.     

Avoiding a stoma

Total proctocolectomy and ileostomy for Crohn's colitis offers a low recurrence rate but commits patients to a permanent ileostomy. In contrast, segmental resection may predispose patients to recurrence and further surgery but may delay or avoid a stoma in select individuals. AIM: This study was undertaken to determine the risk of recurrence and the need for permanent stoma in patients treated with segmental or abdominal colectomy for Crohn's colitis. METHODS: Between 1976 and 1985, 699 patients underwent surgery for Crohn's colitis at the Mayo Clinic. Patients who had a total proctocolectomy and end ileostomy or primary ileal or anorectal disease were excluded from further study. Fifty-three patients had a colon resection without a permanent stoma, and 49 were alive and available for follow-up. During a mean follow-up of 14 years, completed questionnaires provided current details on subsequent medical and surgical therapies and/or stomas that were required. In these 49 patients, Crohn's of the colon involved the right, left, and both sides of the colon in 12, 31, and 6 patients, respectively, and involved less than one-third, one to two-thirds, and greater than two-thirds of the colon in 23, 25, and 1 patients, respectively. RESULTS: Twenty-two of fortynine patients (45 percent) required no further therapy. In 27 patients (55 percent), further treatment was required, including 11 (22 percent) patients who were managed medically (only 4>1 year) and 16 (33 percent) patients who were managed surgically. Three recurrences developed in the small bowel; the remaining 24 developed in the colon. For the 16 patients with recurrence requiring surgery, mean time to recurrence was 51±14 months; in all cases, recurrent disease involved the colon, with four anastomotic recurrences. At first recurrence, ten patients underwent another limited colon resection, and six patients underwent completion proctectomy with permanent ileostomy. Five patients required a third procedure, only one of which resulted in a permanent ileostomy. Therefore, 42 patients (86 percent) remained stoma-free, and 7 (14 percent) ultimately required permanent ileostomy, with a mean stoma-free interval of 23±4 months. CONCLUSION: Colon resection without proctectomy in select patients with limited colonic Crohn's disease can delay or avoid the necessity of a permanent stoma.Read at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 9 to 14, 1996.     

Ileorectal anastomosis for inflammatory disease of the colon

Summary 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 were three 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 mortality. 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. Read at the meeting of the American Society of Colon and Rectal Surgeons, New Orleans, Louisiana, May 2 to 6, 1976.     

Factors which influenced postoperative complications in patients with ulcerative colitis or Crohn's disease of the colon on corticosteroids

A retrospective analysis was undertaken of the records of 107 patients with Crohn's disease of the colon or with ulcerative colitis who underwent 162 operations under steroid cover. The study revealed no correlation between steroid dosage and postoperative morbidity or mortality. The incidence of wound dehiscence and incisional hernia compared favourably with the reports of other unselected series of similar patients. Contamination did significantly influence results. Septic complications were more frequent when the operative field was contaminated and both delayed wound healing and mortality were related to this sepsis. A `clean and dirty' technique was effective in controlling contamination during elective bowel division but preoperative bowel perforation and accidental entry into the lumen of the bowel during dissection were potentially avoidable sources of contamination. Primary healing of the perineal wound after proctocolectomy was seldom achieved in contaminated patients where a drain tube was brought out through the main perineal incision. When perineal sinuses or fistulae followed a proctocolectomy, patients with Crohn's disease had a significantly slower rate of healing than did patients with ulcerative colitis. However, there was no difference in the healing of abdominal wounds in relation to the primary pathology. Even abdominal incisions which were used on more than one occasion healed as well as those which were used for the first time. A prophylactic antibiotic regime of either ampicillin or tetracycline offered little protection against postoperative sepsis. The organisms which caused such infections were often insensitive to the two antibiotics.     

Is an ileal pouch an alternative for patients requiring surgery for Crohn's proctocolitis?

Background Most surgeons consider Crohn's colitis to be an absolute contraindication for a continent ileostomy, due to high complication and failure rates. This opinion may, however, be erroneous. The results may appear poor when compared with those after pouch surgery in patients with ulcerative colitis (UC), but the matter may well appear in a different light if the pouch patients are compared with Crohn's colitis patients who have had a proctocolectomy and a conventional ileostomy. Methods We assessed the long–term outcomes in a series of patients with Crohn's colitis who had a proctocolectomy and a continent ileostomy (59 patients) or a conventional ileostomy (57 patients). The median follow–up time was 24 years for the first group and 27 years for the second group. Results The outcomes in the two groups of patients were largely similar regarding both mortality and morbidity; the rates of recurrent disease and reoperation with loss of small bowel were also similar between groups. Conclusions The possibility of having a continent ileostomy, thereby avoiding a conventional ileostomy—even if only for a limited number of years—may be an attractive option for young, highly motivated patients.     

Long-term ileostomy complications in patients with ulcerative colitis and Crohn's disease

Ileostomy complications in 203 patients operated on with proctocolectomy and ileostomy for ulcerative colitis and Crohn's disease were investigated prospectively. The patients were examined at regular intervals by interview and thorough examination of the stoma. Stomal dysfunction was carefully assessed and patients presenting with surgical complications were admitted for reconstruction. The crude rate of ileostomy complications necessitating reconstruction was 34% and significantly higher in patients with Crohn's disease compared with patients with ulcerative colitis. The cumulative rate of surgical revision after 8 years was 75% in the former group and 44% in the latter. Ileostomy stenosis and sliding recession were the two most common indications for reconstruction. Eighty-three per cent of the revisions were performed as local procedures, making a formal laparotomy unnecessary. Causative factors such as surgical technique, length of concomittant ileal resection and postoperative weight gain were analysed for possible influence on the rate of reconstruction, but no significant association was identified.     

Microsatellite Instability Is Uncommon in Intestinal Mucosa of Patients with Crohn's Disease

Patients with long-standing inflammatory bowel disease have an increased risk for colorectal carcinoma. Microsatellite instability occurs in colonic neoplasms and has been reported in colonic tissues from patients with ulcerative colitis. Patients with Crohn's disease also have an increased risk for colorectal cancer, although it is lower than that associated with ulcerative colitis. This study was designed to determine whether microsatellite instability occurs in Crohn's disease, and whether it occurs with similar frequency to that observed in ulcerative colitis. In all, 177 tissue samples from 33 patients with Crohn's disease were evaluated for microsatellite alterations. Microsatellite instability occurred in five different tissue samples from one of 33 Crohn's disease patients. Four of the five tissue samples showed microsatellite instability at more than one locus. We conclude that microsatellite instability is less common in Crohn's disease than ulcerative colitis and may reflect differences in cancer risk between these two forms of inflammatory bowel disease.     

The Cause of Death in Inflammatory Bowel Disease: A Comparison of Death Certificates and Hospital Charts in Rochester, New York

Objective: This study examines the causes of death from Crohn's disease and ulcerative colitis by comparing death certificates with hospital charts as part of an ongoing, community-based analysis in Rochester, NY. Methods: A registry of 1358 inflammatory bowel disease patients followed from January 1973 to December 1989 was analyzed for the cause of death by a study of death certificates as well as by a study of hospital records, including surgical pathology and autopsy records. A panel of physicians defined specific criteria for diagnosis, cause of death, and relation of death to inflammatory bowel disease. Results: One hundred and thirty patients (59 with ulcerative colitis and 71 with Crohn's disease) from the registry were found to have death certificates recorded by Monroe County during this period. There was an 80% concordance of the death certificate to the hospital record for the cause of death and its relationship to inflammatory bowel disease. Discordance was noted in cases of colon cancer and surgical complications. Conclusions: Sixty-eight percent of Crohn's disease and 78% of ulcerative colitis patients died from causes unrelated to their inflammatory bowel disease. Deaths caused by Crohn's disease decreased from 44% in the 1973–1980 period to 6% in the 1981–1989 period. Crohn's disease was it direct cause of death in 25% of the female patients, whereas only 6% of male patients died directly of Crohn's disease. Colorectal cancer caused 14% of the deaths in ulcerative colitis patients, three times more often than in Crohn's disease patients. Excluding cancer, there were only two deaths directly due to ulcerative colitis, both in the first 2 yr after diagnosis.     

Surgical therapy for Crohn's disease

Most patients with Crohn's disease will require at least one operation for that condition, either an operation to correct a complication of Crohn's disease (abscess, fistula, or bleeding) or for intractability (the failure of medical management to provide relief of disabling symptoms). Proper timing of surgery and careful preoperative preparation of the patient with special attention to control sepsis and to improving nutritional status will make the operation safer. Because of the tendency for Crohn's disease to progress despite medical or surgical therapy recurrences after operation are common and the surgical procedure should be limited to correcting the complication at hand. For Crohn's disease of the small bowel or of the terminal ileum and right colon, a conservative intestinal resection and anastomosis is usually the procedure of choice; nonresective procedures such as bypass and strictureplasty are useful in special situations. More than half of the patients so treated will eventually develop recurrence that may require one or more subsequent operations. The adverse effects of resection will be minimized by conservative surgery and by careful long-term management of the altered intestinal physiology. Some patients with Crohn's colitis have limited colonic disease where continence can be preserved by resection and anastomosis, although the recurrence rate is high. Total proctocolectomy for Crohn's colitis provides much better assurance of long-term freedom from recurrence but at the cost to the patient of a permanent ileostomy. Surgery for Crohn's disease is not curative but offers effective palliation for the complications of this progressive and poorly understood condition.     

Ileostomy adenocarcinomas in the setting of ulcerative colitis

Adenocarcinomas arising at ileostomy sites in patients after colon resection for various diseases, such as ulcerative colitis (UC), familial adenomatous polyposis coli, and Crohn's disease, are rare occurrences but have been reported increasingly in the last 20 years. We report a case of adenocarcinoma arising in an ileostomy site in an 85-year-old woman with longstanding UC. She had pancolitis and underwent total proctocolectomy. Thirty-nine years later, her ileostomy site developed a granulation tissue-type lesion, which on initial biopsy revealed cytologic atypia in the presence of marked inflammation. A subsequent biopsy revealed adenocarcinoma with signet-ring cells and abundant extracellular mucin. Resection of the ileostomy was undertaken and a new ileostomy was performed. The literature on adenocarcinoma arising in the 23 patients with ulcerative colitis who received a Brooke or Kock ileostomy and had no prior history of neoplasm is reviewed.     

Crohn's Disease presenting as Isolated Jejunitis Years after Childhood Colitis

We present a case of a patient who had documented ulcerative colitis as a child and later presented with isolated Crohn's jejunitis. Although rare, Crohn's disease must be considered in those patients with segmental inflammation of the small bowel and a prior history of inflammatory bowel disease involving the colon. Patients with colitis that do not show specific criteria for either ulcerative colitis or Crohn's disease should be classified as indeterminant colitis, and a small bowel series is indicated. It may be indicated to obtain a small bowel series in patients with any form of colonic inflammatory bowel disease, periodically, after diagnosis.     

Stomal adenocarcinoma in Crohn's disease.

Malignant change occurring at the site of a stoma in two patients with proved Crohn's disease is described. Patients with ulcerative colitis have an increased risk of colonic malignancy and Crohn's disease is also associated with both small and large bowel carcinoma. Most previous reports of stomal carcinoma have been associated with ulcerative colitis although Crohn's disease seems to carry a greater risk of associated small bowel carcinomas. This is the first report of stomal carcinoma complicating Crohn's disease. Epithelial dysplasia is associated with gastrointestinal carcinomas in both ulcerative colitis and Crohn's disease and a dysplasia-carcinoma sequence has been suggested as the origin of these tumours. In both our patients with stomal adenocarcinoma, dysplasia was identified in adjacent tissues, which suggests a similar mechanism. Malignant change should be suspected if epithelial dysplasia is discovered in a biopsy specimen from the mucosa of an ileostomy in Crohn's disease, and this risk is increased if the dysplasia is of a high grade.     

Indeterminate colitis

The term indeterminate colitis has been used to describe cases of inflammatory bowel disease that cannot be classified as ulcerative colitis or Crohn's disease. However, this term has suffered varying definitions, which in addition to numerous difficulties in diagnosing inflammatory bowel disease has led to much confusion. The term indeterminate colitis should only be used in cases where a colectomy has been performed and the overlapping features of Crohn's disease and ulcerative colitis do not allow a definitive diagnosis. Over time the majority of patients remain with a diagnosis of indeterminate colitis, or show symptoms similar to ulcerative colitis. Ileal pouch-anal anastomosis surgery can be performed in such patients, with outcomes of pouch failure and functional outcome that are similar to those in patients with ulcerative colitis but with increased risk of postoperative pouch complications. This review addresses the definition of indeterminate colitis, its pathology, natural history, and outcomes of restorative proctocolectomy.     

Cancer in inflammatory bowel disease

Patients with long-standing inflammatory bowel disease （IBD） have an increased risk of developing colorectal cancer （CRC）. Many of the molecular alterations responsible for sporadic colorectal cancer, namely chromosomal instability, microsatellite instability, and hypermethylation, also play a role in colitis-associated colon carcinogenesis. Colon cancer risk in inflammatory bowel disease increases with longer duration of colitis, greater anatomic extent of colitis, the presence of primary sclerosing cholangitis, family history of CRC and degree of inflammation of the bowel. Chemoprevention includes aminosalicylates, ursodeox, ycholic acid, and possibly folic acid and statins. To reduce CRC mortality in IBD, colonoscopic surveillance with random biopsies remains the major way to detect early mucosal dysplasia. When dysplasia is confirmed, proctocolectomy is considered for these patients. Patients with small intestinal Crohn＇s disease are at increased risk of small bowel adenocarcinoma. Ulcerative colitis patients with total proctocolectomy and ileal pouch anal- anastomosis have a rather low risk of dysplasia in the ileal pouch, but the anal transition zone should be monitored periodically. Other extra intestinal cancers, such as hepatobiliary and hematopoietic cancer, have shown variable incidence rates. New endoscopic and molecular screening approaches may further refine our current surveillance guidelines and our understanding of the natural history of dysplasia.     

Split ileostomy and ileocolostomy for Crohn''s disease of the colon and ulcerative colitis: a 20 year survey

The clinical course of 140 patients who have had a split ileostomy for ulcerative colitis or colonic Crohn's disease over a 20 year period is reported. In 37 patients with ulcerative colitis there was no sustained improvement. In the 102 patients with Crohn's disease there was an immediate clinical improvement in 95, which was sustained in 65. Thirty patients have subsequently required a proctocolectomy for persistent inflammation, and 28 are still defunctioned. Bowel continuity was restored after 61 split ileostomies and in 44 patients intestinal continuity remains intact at the present time (mean follow up since closure = 62.5 months, range 0-231 months). It is concluded that a split ileostomy is a safe conservative operation producing at least temporary improvement in severely ill and malnourished patients with Crohn's colitis, and that if a subsequent resection becomes necessary it may be less extensive than was thought applicable at the initial operation. In 27 patients a resection has not been required.     

Chronic inflammatory bowel disease and cancer

Colorectal cancer represents the major cause for excess morbidity and mortality by malignant disease in ulcerative colitis as well as in Crohn's disease. The risk for ulcerative colitis associated colorectal cancer is increased at least 2-fold compared to the normal population and colorectal cancer is observed in 5.5-13.5% of all patients with ulcerative colitis and 0.4-0.8% of patients with Crohn's disease. Established risk factors include long duration of the disease, large extent of the disease, low activity of the disease, young age at onset, presence of complicating primary sclerosing cholangitis or stenotic disease and possibly lack of adequate surveillance, inadequate pharmacological therapy, folate deficiency and non-smoking. Crohn's disease is associated with an increased risk of colorectal carcinoma in patients with long-standing disease, strictures and fistulae under the condition that the colon is involved, tumors of the small intestine may occur occasionally. Extracolonic malignancies are rare, with the exception of biliary tract cancer. Ulcerative colitis associated colorectal cancer typically can occur in the entire colon, is often multifocal and of undifferentiated histology. Stage distribution and prognosis of ulcerative colitis associated colorectal cancer appears to be similar to that of sporadic colorectal cancer with an overall survival of about 40% (15-65%) after 5 years with tumor stage at diagnosis being the most important predictive parameter for survival. Tumor markers helpful for the diagnosis of sporadic colorectal cancer fail to differentiate between inflammatory response and malignant transformation. In contrast the histologic evidence of dysplasia was shown to be a strong indicator of underlying carcinoma or developing malignant transformation. The presence of a surface projection termed dysplasia associated lesion or mass is highly indicative of underlying or associated cancer. While the routinely performed search for dysplasia is hampered by high interobserver variation the demonstration of DNA-aneuploidy or genetic changes which may confirm the ongoing malignant transformation has not yet become clinical routine. The genetic alterations found in ulcerative colitis associated colorectal cancer involve many of the same targets found in sporadic colorectal tumors and include multiple sites of allelic deletion, microsatellite instabilities, and mutations of APC, p53, Ki-ras as well as MSH2 and other genes. The progression of dysplasia to carcinoma is generally accompanied by an accumulation of these mutations and the similarities in the biology of colorectal cancer associated with ulcerative colitis and sporadic colorectal cancer appear to outweigh their difference. In regard to the management of dysplasia and cancer, the role of surveillance programs for the early detection of ulcerative colitis associated colorectal cancer at a curable stage is still under debate. Although these programs failed at tumor prevention and lethal carcinomas are still found inadvertently in patients under surveillance, the majority of surveillance programs could reduce mortality by detecting more cancers at a still curable stage. Current recommendations for surveillance include, therefore, biennial colonoscopy with extensive biopsies after 8-10 years of total colitis or after 15-20 years of left-sided colitis. In the presence of cancer or unequivocal high-grade dysplasia and/or dysplasia associated lesion or mass proctocolectomy is considered adequate. The evidence of low-grade dysplasia should be confirmed before proctocolectomy is considered.     

Ileostomy with the EEATM stapler

The EEA ^TM instrument was used to perform ileostomy in three patients. Two female patients with complications of Crohn's colitis underwent total colectomy and proctocolectomy, respectively. The first patient was operated upon because of toxic megacolon and the second patient for severe perianal disease. A third male patient underwent total colectomy for severe ulcerative colitis that failed to respond to medical therapy. In all patients, ileocutaneous anastomosis was performed with the EEA stapler (ILS, Ethicon). No serious complications were observed except for slight retraction of the ileostomy in one patient after he had gained 22 pounds.     

Complications after ileal pouch-anal anastomosis

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is currently the procedure of choice for ulcerative colitis patients who require colectomy. Despite its wide acceptance, a variety of long-term complications of the procedure exist that can be severe and even lead to pouch excision. Pouchitis occurs in up to one half of patients after IPAA, but is usually well controlled with medical therapy. A small percentage of patients develop chronic persistent pouchitis, which often requires long-term medical therapy and may result in pouch failure. Fistulas and strictures can also complicate the pouch procedure. In general, patients with Crohn's disease are not usually offered IPAA, because recurrence of disease, fistulas, abscesses, and strictures may lead to a higher incidence of pouch failure. Some ulcerative colitis patients develop complications after IPAA and are subsequently diagnosed with Crohn's disease. These patients may develop refractory fistulas, strictures, and extraintestinal manifestations of inflammatory bowel disease. Neoplastic transformation of the pelvic pouch has also been reported, particularly in patients with chronic pouchitis. Thorough follow-up and endoscopic surveillance with biopsies of the ileal pouch are therefore recommended.     

Excisional surgery with ileostomy for Crohn's colitis with particular reference to factors affecting recurrence

This paper reports the indications for, and results of, excision of the large intestine with ileostomy in 73 patients with Crohn's colitis who have been followed for a mean of nine years since resection. Sixty-four of them are still alive and all but two of the survivors are now in good health.However, 23 (33%) have developed recurrent Crohn's disease since resection. This is higher than that reported in many other series and may be due to differences in the length of follow up, the site and extent of colonic disease, the age of the patient at the time of excision with ileostomy, and differences in the pathological interpretation of the diagnosis of Crohn's disease. The high recurrence rate in this series lends caution to the view that the prognosis after excisional surgery and ileostomy for Crohn's colitis is as good as after the same operation for ulcerative colitis and should influence the decision when the alternative of medical or surgical management are being considered for patients with Crohn's colitis.     

Endoscopic surveillance in Crohn's disease and ulcerative colitis: who needs what and when?

Crohn's disease and ulcerative colitis are chronic inflammatory diseases resulting from an inappropriate innate and adaptive immune response towards commensal microbiota. Patients with Crohn's disease and ulcerative colitis carry an increased risk of developing colon cancer and/or small bowel carcinoma, respectively. The colorectal cancer risks of ulcerative colitis and Crohn's disease with comparable surface area involvement and disease duration are very similar. Early disease onset, disease extent, severity of inflammation, a family history of sporadic colorectal cancer, efficacy and duration of medical therapy, coexisting primary cholangitis and mucosal dysplasia are all risk factors for colorectal cancer. Regular endoscopic surveillance is endorsed by leading professional societies and outlined in guidelines and consensus statements. The yield of endoscopic surveillance, particularly to detect dysplasia, can be improved with chromoendoscopy with methylene blue dye spray-targeted biopsies, autofluorescence plus high-resolution endoscopy, chromoendoscopy-guided confocal laser microscopy and confocal laser microscopy in combination with narrow band imaging and high-resolution endoscopy. Proper bowel preparation, complete, careful inspection of the entire colon, a minimum withdrawal time and adherence to recommended management guidelines ensure a high-quality study and improve surveillance. Dysplasia can be graded by the Vienna or Riddell classification. Colectomy is recommended for patients with flat high-grade dysplasia confirmed by an expert gastrointestinal pathologist.