Crohn's Disease

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 pateints 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.     

Crohn''s Disease of the Colon

Retroperitoneal lumbocrural abscess occurred in 12 patients of 231 with Crohn's colitis or ileocolitis. Although all patients with this complication fell within the group of 175 ileocolitis patients, at least four originated in fistulous tracts of the colon. Eleven of the 12 abscesses developed spontaneously as the first major complication of the disease. The prominent clinical features included pain radiating down the thigh, hip joint flexion, difficulty in walking, hydronephrosis and hydroureter. Internal and external fistulas were significantly more common in the abscess group of 12 patients than in the 219 patients without retroperitoneal abscess. Radiological evidence of granulomatous disease was found in all patients; fistulous tract formation was characteristic and the development of extraperitoneal gas bubbles, in four patients, pathognomonic of abscess with gast-forming organisms. In the presence of established retroperitoneal abscess, the surgical sequence suggested is drainage synchronous with, or followed by diversion and ultimately definitive resection. Resection with anastomosis should not be carried out in the presence of an acute inflammatory process with frank abscess or free pus communicating with the peritoneal cavity. The spontaneous development of retroperitoneal abscess is a serious development in the natural history of Crohn's (ileo) colitis. It frequently heralds the first of a series of operative procedures to deal with the abscess. It sequels are enterocutaneous fistulas and further extension of the disease process.     

A Case of Crohn's Disease which Initially Presented with Diffuse Inflammation in the Rectum and Sigmoid Colon

Abstract: This case report describes a female patient with Crohn 's disease who had diffuse proctosigmoiditis without a longitudinal ulcer or cobblestone appearance at the initial attack. She was treated with sulfasalazine on the presumptive diagnosis of ulcerative colitis. Two and a half months later, painful ulcers in the oral cavity and a deep longitudinal ulcer in the sigmoid colon were found, and a non-caseous granuloma was revealed in the biopsy specimens taken from the sigmoid colon. A definitive diagnosis of Crohn's disease was established from these findings and treatment with a corticosteroid was effective.     

Crohn''s Disease of the Colon

The development of internal fistulas, fistulous tracts or external fistulas is extremely common in Crohn's disease of the colon occurring in 39% of patients in this series.
Fistulas, which usually originate in small bowel, particularly internal fistulas, are more common in ileocolitis. Nevertheless, in this series, a significant number, 23% of all fistulas (excluding anorectovaginal fistulas) and 37.5% of external fistulas, commenced in diseased colon.
Patients with such fistulas tend to have a more complicated course; with a significantly higher incidence of intraabdominal abscess formation and in granulomatous colitis, a higher incidence of extraintestinal complications.
Surgical intervention was required significantly more often in fistula patients than in the control series (82% vs. 49%).
The number of external fistulas following by-pass is significantly greater than that following resection (P < 0.01).     

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.     

Crohn's Disease of the Esophagus

A 26-yr-old woman presented with odynophngia, dysphagia, and intermittent bloody stools. Clinical, endostopic, and microseopic evidence confirmed the diagnosis of severe Crohn's disease of the oropharynx, esophagus, proximal stomach, terminal ileum, and colon.     

Crohn's Disease of the Appendix

A case of Crohn's disease of the appendix (presenting as acute appendicitis) is reported. The problem of appendiceal involvement in Crohn's disease is reviewed.     

Endoscopy and Crohn's Disease: Endoscopic Approach to the Pathogenesis of Crohn's Disease

Abstract: This review describes endoscopic and histopathological findings in Crohn's disease with reference to its pathogenesis. The number of patients with Crohn's disease has markedly and rapidly increased during the last 10 years in Japan. Minute lesions such as aphthoid ulcers as an early lesion in Crohn's disease were at first discussed endoscopically and histopathologically. Recent advances concerning the mechanism of how aphthoid ulcers may occur revealed that they are induced by mucosal ischemia due to vasculitis. Longitudinal ulcers and cobblestone appearance were observed only in advanced Crohn's disease. Finally, the etiology of Crohn's disease was reviewed from the viewpoint of infectious agents and immunological abnormalities which were clarified from the study of endoscopic biopsy specimens.     

Metastatic Crohn's Disease

The case of a 25-yr-old female with Crohn's disease who developed recurrent erythematous nodules on her lower extremities is described. These nodules enlarged and ulcerated. Repeated bacterial, fungal, and acid-fast cultures remained negative. A skin biopsy revealed noncaseating granulomata, confirming the diagnosis of cutaneous "metastatic" Crohn's disease. The lesions completely resolved with systemic corticosteroid therapy. Although cutaneous metastatic Crohn's disease is uncommon, patients with Crohn's disease who develop unusual skin lesions that persist should have them biopsied.     

Miliary Crohn's Disease

Miliary Crohn's disease, an unusual variant of Crohn's disease, must be distinguished from lymphoma and tuberculosis. We present a patient with this entity and offer suggestions to the diagnostic approach to a nodular lesion in the small bowel.     

Perianal Crohn's Disease

Perianal Crohn’s disease usually is associated with involvement of another primary site of Crohn’s disease. However, there is conflicting evidence on the relationship between proximal disease activity and perianal symptoms. Therefore, although it is reasonable to treat active proximal disease, symptomatic perianal disease may have to be treated on its own right. Hemorrhoids and anal fissures are best treated medically. Fistulae and abscesses are treated with control of sepsis and resolution of inflammation while preserving continence and quality of life. Abscesses require surgical drainage, which needs to be prolonged for healing to be complete. Fistulae may be treated with medications first, especially if the rectum is diseased. Refractory fistulae respond better to surgical treatment and sometimes require fecal diversion. The medical management of patients with perianal Crohn’s disease consists of rectal mesalamine, systemic antibiotics, immunosuppressive agents, and infliximab. The role of infliximab is evolving and it may reduce the need for surgical intervention in some cases. Perianal hygiene and skin protection help to reduce local discomfort.     

Anal Crohn's Disease

Background: Anal lesions as first manifestation of Crohn's disease can cause difficulties in differential diagnosis especially, when morphologic intestinal changes and, histologically, epitheloid granulomas cannot be demonstrated early. Case Reports: We present a 19-year-old femal patient with atypical anal fissures and a 76-year-old male patient with a circular anal stenosis leading to the diagnosis Crohn's disease which could be proved later. Conclusion: In case of anal fissures or ulcerations Crohn's disease has to be considered, also when endoscopic preexaminations had excluded morphologic equivalents of this disease. We would like to stress that in these cases a repetition of such invasive diagnostic features can be necessary.     

Crohn's Disease in the Elderly

To determine the features of Crohn's disease in elderly patients we reviewed the charts, roentgenograms and pathology of patients with Crohn's disease admitted to our hospital from 1966 through 1979. Thirty-three patients (5.2% of the total) had the onset of symptoms and diagnosis made after age 60, including 18 (55%) with ileitis alone, 11 with colitis and four with ileocolitis. Six patients were seen, four with colitis and two with ileocolitis, with acute toxicity requiring early surgery. The clinical, radiographic and histologic characteristics of the disorder in older patients were otherwise similar to those described in younger patients. Differentiation of ischemic bowel disease and diverticulitis from Crohn's disease in such patients was difficult without reliance on histologic as well as clinical and roentgenographic features. Fifty-eight per cent of these older patients eventually required surgery, including 10 of 11 (91%) with colitis, two of four with ileocolitis and seven of 18 (39%) with ileitis. The cumulative clinical recurrence rate, limited to patients with ileal disease, was 21% at nine years and 37% at 15 years.     

Epidemiology of Crohn's Disease

Although our current understanding is limited, epidemiologic investigation of Crohn's disease holds great promise. Certain aspects of the epidemiology are clear. The incidence of Crohn's disease, which has increased over the past few decades, may have reached a plateau. The disease has its peak onset in early life, with a second peak among the elderly. It is more common in the developed countries and among Jews. Whether the disease is related to occupation, social class, marital status, stress, infection, diet, smoking, and oral contraceptives is less certain. This paper reviews the epidemiology of Crohn's disease and proposes areas in which further research is needed.