Crohn's Disease of the Colon

Using accepted diagnostic criteria we have selected, for study, 160 patients with Crohn's disease involving the colon. There is a remarkable discrepancy between the clinical diagnosis prior to or at the time of initial admission to this hospital and the diagnosis following definitive investigation and observation of the progression of disease.
The peak age incidence occurred in the second decode The colitis group showed a greater percentage of patients over 30 years of age. Although histopathology was not obtained in all patients, there appeared to be sparing of the ascending colon in a small percentage (9%) of patients with ileocolitis.
Comparison of the clinical features of granulomatous disease limited to the colon and granulomatous ileocolitis shows a significantly greater incidence of extraintestinal symptoms and overt bleeding in the former. Nausea, vomiting, subacute obstruction, abdominal mass and internal fistulas were substantially more common in ileocolitis but the difference was not statistically significant. In this series retroperitoneal abscess did not occur in patients with disease localized to the colon. In the 10 patients with ileocolitis who developed an abscess, however, the site of fistula was the colon in four patients. In one of these, the abscess was left-sided.     

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).     

Psoas Abscess in Inflammatory Bowel Disease

The inflammatory bowel disease (IBD) is sometimes complicated by the development of a psoas abscess. We recently encountered three patients of IBD with psoas abscess. Two patients had Crohn's ileocolitis and one with ulcerative colitis. During 1979-1984, 23 patients with psoas abscess due to a variety of underlying disease processes were seen at our institution. At the same time period, 483 cases of Crohn's disease and 283 cases of ulcerative colitis were encountered. Therefore, of 766 patients with IBD only three were complicated by psoas abscess (incidence ratio = 0.6%). Thus, psoas abscess was a very rare complication of IBD in patients seen at our institution. In our series of 23 psoas abscess patients, IBD was not a major causative factor. Additionally, to our knowledge, psoas abscess complicating ulcerative colitis has not been reported previously.     

Liver Abscess in Crohn's Disease

Liver abscess is a rare but serious complication of Crohn's disease. Intra-abdominai abscesses, fistulous disease, and metronidazole or steroid therapy have all been reported to be important predisposing factors in the pathogenesis of the disease, and the mortality has been reported to he high. We report six patients who developed a liver abscess as a complication of Crohn's disease. Three patients presented with a liver abscess as the first manifestation of Crohn's disease and two others bad quiescent disease at presentation. Ibe diagnosis was delayed by 1–8 wk after the onset of fever because of the paucity of signs indicating a bepatic infection. None of the patients had intra-abdominal abscesses, active fistulas, or metronidazole therapy before the onset of symptoms. The only predisposing conditions identified were two minor skin infections in patients developing staphylococcal liver abscesses. Nonoperative catheter drainage was successful in four of the six patients. One patient required surgical placement of drains, and the patient with the longest delay before diagnosis required hepatic lobectomy because of extensive necrosis. Shaking chills, fever with leukocytosis, and an elevated alkaline phosphatase are suggestive of a liver abscess and should prompt an ultrasound examination. Catheter drainage with antibiotic therapy is effective if the liver abscess is diagnosed before extensive necrosis has occurred. Minor skin infections may predispose to stapbylococcal liver abscess in some cases.     

Giant Pseudopolyps in Crohn's Colitis

Six patients with Crohn's disease had colonic intraluminal multilobulated masses detected on barium enema. Four had Crohn's colitis and two ileocolitis. The mean duration of disease was four and eight tenths years. Three patients underwent surgery and three had colonoscopy with multiple biopsies and cytology. Pseudopolypoid inflammatory tissue was found in each case. One patient died after a prolonged postoperative course due to sepsis and abscess formation. No surgery was performed in three patients and follow-up colonoscopic examinations at four and a half years revealed no change in these findings.
The presence of an intraluminal colonic mass in Crohn's colitis may mimic a neoplasm. If surveillance with x-ray, endoscopic biopsies and cytology reveals pseudopolypoid inflammatory tissue then surgery is not mandatory. Pseudopolypoid inflammatory tissue has never been associated with carcinoma.     

Psoas Abscess Complicating Crohn''s Disease

Psoas abscess classically was described as secondary to tubercular spondylitis but now more frequently is a complication of an intraabdominal process such as Crohn's disease. Less well recognized is that the fever, flexion contracture of the hip, and weight loss characterizing psoas abscess may be the first indications of Crohn's disease; in fact, gastrointestinal symptoms may be completely absent. Psoas abscess was the first sign of Crohn's disease in 11 of 46 reported patients. We present three additional patients; two were asymptomatic before psoas abscess formation. Only seven of 26 patients whose sole surgical procedure was drainage had subsequent resolution of the abscess. When drainage was combined with bowel resection, 14 of 18 patients (77.8%) were cured by the initial procedure. Thromboembolic complications occurred in four patients (8.3%). Effective therapy when psoas abscess complicates Crohn's disease, includes appropriate antibiotics, drainage, resection of fistulous intestine, and antithrombotic prophylaxis.     

Gastric and duodenal fistulas in Crohn's disease

We report gastric or duodenal fistulas in 6 patients with Crohn's colitis or ileocolitis. Two patients had duodenocolic fistulas, 1 had a duodenoileal fistula, 2 had gastrocolic fistulas, and 1 had gastric and duodenal fistulas from an ileocolic anastomosis. In each case the fistula originated from the lower bowel segment, and no patient in this series had primary gastroduodenal Crohn's disease. These cases illustrate the range of manifestations of fistulas to the stomach and duodenum in Crohn's disease, and emphasize that the predominant symptoms determining surgical intervention usually arise from the diseased ileum and colon, rather than from the fistula. Our experience demonstrates the simplicity and safety of excision of the fistula with primary closure of the stomach or duodenum when the stomach and duodenum are otherwise normal by endoscopic examination.     

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.     

Olsalazine is not superior to placebo in maintaining remission of inactive Crohn's colitis and ileocolitis: a double blind, parallel, randomised, multicentre study

BACKGROUND AND AIMS: The benefit of 5-aminosalicylic acid therapy for maintenance of remission in Crohn's disease is controversial. The primary aim of this study was to evaluate the prophylactic properties of olsalazine in comparison with placebo for maintenance of remission in quiescent Crohn's colitis and/or ileocolitis. METHODS: In this randomised, double blind, parallel group study of olsalazine versus placebo, 328 patients with quiescent Crohn's colitis and/or ileocolitis were recruited. Treatment consisted of olsalazine 2.0 g daily or placebo for 52 weeks. The primary end point of efficacy was relapse, as defined by the Crohn's disease activity index (CDAI) and by clinical relapse. Laboratory and clinical disease activity indicators were also measured. Safety analysis consisted of documentation of adverse events and laboratory values. RESULTS: No differences in the frequency of termination due to relapse or time to termination due to relapse were noted between the two treatment groups (olsalazine 48.5% v placebo 45%) for either colitis or ileocolitis. The failure rate, defined as not completing the study, was significantly higher in olsalazine treated patients compared with placebo treated patients for the overall population (colitis and/or ileocolitis: olsalazine 65.4% v 53.9%; p=0.038). Similar failure rates were seen for patients with colitis. A significantly higher percentage of olsalazine treated patients experienced adverse gastrointestinal events. Drug attributed adverse events were reported more frequently in the olsalazine treated group with gastrointestinal symptoms being causally related to olsalazine treatment (olsalazine 40.7% v placebo 26.9%; p=0.010). Back pain was reported significantly more often by the placebo treated group. However, serious medical events did not differ between the two groups. Adverse events led to more early withdrawals in the olsalazine treated group than in the placebo treated group; thus average time in the study for patients in the olsalazine treatment group was significantly shorter than that of patients in the placebo group. CONCLUSIONS: Patients treated with olsalazine were more likely to terminate their participation in the trial than those taking placebo. This difference was not related to relapse of disease, as measured by CDAI and clinical measures, but rather was due to the development of intolerable adverse medical events of a non-serious nature related to the gastrointestinal tract. The gastrointestinal related events in the olsalazine treated group may be due to the difference in gastrointestinal status at baseline which favoured the placebo treatment group.     

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.     

Pelvic Osteomyelitis Complicating Crohn''s Disease: Diagnosis by Computed Tomography

An unusual case of pelvic osteomyelitis complicating granulomatous ileocolitis is herein reported. Computed tomography of the abdomen was crucial in detecting osteomyelitis of the right iliac wing as well as the associated fistulous tracts and abscesses adjacent to the involved bone. Clinical and radiographic features of this rare complication of Crohn's disease are presented, together with a brief review of the pertinent literature.     

Factors influencing first relapse in patients with Crohn's disease.

To determine whether information available at time of diagnosis of Crohn's disease can predict initial clinical course, I followed 239 patients prospectively from time of diagnosis to initial relapse. The patient's sex, smoking habits, contraceptive usage, disease extent, and presence of granulomas in the first histological specimen were recorded. No association was found between this demographic data and the interval between onset of symptoms and diagnosis, the severity of symptoms at presentation, or the time to relapse. The type of relapse, however, was influenced by the type of the first attack; 70% of relapses were of the same type as the initial attack. Cigarette smoking was associated with ileocolitis (p = 0.028). There was a trend for oral contraceptive users to have ileocolitis, whereas the presence of granulomas in the first histological specimen was not associated with a specific disease distribution. Patients with ileocolitis had more inflammatory attacks than those with ileitis or colitis (p = 0.001). There was also a trend for cigarette smokers and those on oral contraceptives to have more inflammatory attacks, but the presence of granulomas had no effect on the type of relapse. There is little to assist in prognosis of early disease when the diagnosis of Crohn's disease is first made, although the types of attacks tend to repeat themselves.     

Sterile Epidural and Bilateral Psoas Abscesses in a Patient with Crohn's Disease

Crohn's disease primarily affects the distal gastrointestinal tract, yet it is a systemic disease that can involve nearly any organ. A psoas abscess complicating Crohn's disease is uncommon and usually originates from a fistulous communication with an adherent bowel. Spinal epidural abscess, an extremely rare complication, also appears to arise by fistulization from another organ involved with Crohn's disease. Previous reports indicate that abscesses in these two areas usually contain bacterial organisms, often mixed flora, consistent with seeding from a diseased bowel. This report represents the first case of Crohn's disease complicated by both hilateral sterile psoas abscesses and a coexistent sterile epidural ahscess without evidence of a fistulous communication from the howel. We report this case hecause psoas and epidural abscesses can present without typical signs and symptoms. Once suspected, aggressive diagnostic workup and definitive operative intervention is indicated. Failure to promptly diagnose and treat these ahscesses may result in considerable morbidity.     

Yersinia enterocolitica infection complicated by intestinal perforation

Yersinia enterocolitica causes primarily ileocolitis in human beings, and is manifested by abdominal pain, diarrhea, and fever. Usually, it is a self-limiting disease. Local or systemic complications are rare. A 71-year-old man with Y enterocolitica colitis complicated by perforation and abscess formation is described. This complication is very rare, and the four other cases that have been reported in the literature are reviewed.     

Hydrogen peroxide enhanced ultrasound- fistulography in the assessment of enterocutaneous fistulas complicating Crohn's disease

BACKGROUND/AIMS: Proper management of enterocutaneous fistulas complicating Crohn's disease largely depends on the anatomical characteristics of the sinus tracks as well as the coexistence of complications such as abscesses and distal bowel stenosis. The aim of this prospective study was to evaluate the accuracy of a new technique (hydrogen peroxide enhanced ultrasound (US)-fistulography) compared with conventional x ray fistulogram and/or surgical findings in the detection of Crohn's disease associated enterocutaneous fistulas. METHODS: Patients with known Crohn's disease and a suspicion of enterocutaneous fistulas were prospectively studied with this novel technique, conventional x ray fistulogram, and barium radiography as well as with computed tomography whenever an abdominal abscess was suspected at US. In those undergoing surgery, intraoperative findings were also compared. RESULTS: Seventeen of 502 (3.4%) consecutive patients with Crohn's disease seen over a ten month period had associated enterocutaneous fistulas and were enrolled. Hydrogen peroxide enhanced US-fistulography visualised the extent and configuration of fistula in all cases: 13 patients had a fistula arising from the ileum and two from the sigmoid colon, whereas in two there was no evidence of communication with intestinal loops; in contrast, conventional x ray fistulography missed a correct definition of the fistulous branches or communication with intestinal loops in 50% (4/8) and 36% (4/11) of patients respectively; barium radiography showed fistulas in two cases only. The presence of abscesses along or close to the sinus track, as well as the coexistence of intestinal stenosis, was correctly detected at US in all patients. CONCLUSIONS: Hydrogen peroxide enhanced US-fistulography could be considered the diagnostic procedure of choice in Crohn's disease associated enterocutaneous fistulas, as it is at least as accurate, simple, and safe as conventional x ray fistulogram, does not miss coexisting abdominal complications, and also provides information on the diseased bowel segments. In addition, it can be easily repeated over time in order to monitor the course of fistulas undergoing conservative treatment.     

Endosonographic evidence of persistence of Crohn's disease-associated fistulas after infliximab treatment, irrespective of clinical response.

PURPOSE: Infliximab has been reported to improve fistulizing Crohn's disease. Moreover, prompt healing of mucosal ulcers has been described. Whether fistulas disappear or remainders of fistulas persist is unknown. This study documents fistulous tracts before and after infliximab therapy by means of hydrogen peroxide-enhanced endosonography METHODS: Eight patients with perianal, vaginal, or perineal fistulas were treated with a triplet of infliximab 5 mg/kg infusions. At baseline, and at Week 4 after the last infusion, fistulas were documented by local inspection, digital examination, and hydrogen peroxide-enhanced anal or vaginal endosonography. RESULTS: Patients with vaginal or perineal fistulas did not respond clinically to therapy, whereas patients with perianal fistulas improved considerably. However, in all patents remainders of fistulous tracts were demonstrated by endosonographic techniques. CONCLUSIONS: Short-term treatment of Crohn's disease-associated fistulas with infliximab does not induce disappearance of fistulous tracts, irrespective of therapeutic response.     

Duodenal fistulas in Crohn's disease

Of 1,480 patients with Crohn's disease admitted to The Mount Sinai Hospital between 1960 and 1983, eight (0.5%) had duodenal fistulas (DF), all originating from diseased small or large bowel and not from primary disease of the duodenum. The extent, duration, and major clinical features of Crohn's disease did not differ between patients with DF and those with other fistulas. Six of the patients underwent surgery for refractory disease or abscess formation and two patients were treated medically. All improved and were able to maintain an adequate oral intake after treatment. At follow-up 3-10 years later, the surgically treated patients were well but both medically treated patients had died, one from a probably unrelated brain tumor 7 years after discharge and one from necrotizing pancreatitis 10 years later. Our experience suggests that the presence of a DF is not an absolute indication for early surgery. The initial therapeutic management of such patients should be determined by the nature and severity of the underlying Crohn's disease rather than the presence of a DF. The late pancreatic complication in a patient with a chronic DF, however, raises the question of an association between the two.     

Carcinoma arising in anorectal fistulas of Crohn's disease

PURPOSE: Anorectal fistulas are commonly associated with Crohn's disease. Carcinoma arising in an anal fistula in the absence of Crohn's disease occurs rarely. Carcinoma arising in an anorectal fistula of Crohn's disease is likewise rare and is the subject of this article. METHODS: We have seen eight cases in seven patients. Four of these were squamous carcinoma and three were adenocarcinoma. Details of these seven patients are presented. RESULTS: Two deaths in the four patients with squamous carcinoma and one in the two patients with adenocarcinoma with adequate follow-up suggest a poorer prognosis in both types of malignancy than when these lesions occur without Crohn's disease. CONCLUSION: Carcinoma does arise in the midst of the anorectal fistulas and abscesses of Crohn's disease. Carcinoma arising in a Crohn's disease fistula can be very difficult to diagnose. Examination may be limited by pain, stricture, or induration of the perianal and perineal tissues. Examination under anesthesia can also overlook the lesion. Diagnostic examination under anesthesia yields increases with biopsies or curettage of the fistulous tracts.     

The relationship between granulomatous bowel disease and duodenal ulcer

Of 122 patients with inflammatory bowel disease, 15 had duodenal ulcer disease as well. Duodenal ulcers were present in 9 of 34 patients with Crohn's disease confined to small bowel, 3 of 24 with granulomatous ileocolitis and 3 of 64 with ulcerative colitis. The higher incidence of ulcers in Crohn's disease of both small and large bowel, analyzed either separately or together, was statistically significant compared to the ulcerative colitis group. Gastric analyses revealed no significant differences in gastric acid secretion among the three groups. There was no relation between extent and site of small bowel involvement and gastric acid secretion. The high incidence of ulcers in granulomatous bowel disease remains unexplained.     

Seton management of complex anorectal fistulas in patients with Crohn's disease

Anorectal fistulas associated with Crohn's disease are difficult to manage, particularly when the rectum is diseased. Significant morbidity has been associated with both medical and surgical therapy. Although conventional therapy is acceptable in the management of simple fistulas in Crohn's disease, these approaches often exacerbate rather than ameliorate problems in patients with complex fistulas. The authors report ten cases of complex fistulas in patients with Crohn's disease managed with their technique of long-term, indwelling setons. These setons are placed through the fistula tract and tied loosely to maintain the patency of the fistula without cutting through the sphincters. At the time of insertion, although abscesses are incised and drained, no attempt is made to divide the superficial tissues or sphincter overlying the fistulous tract. The patients ranged in age from 23 to 81 years and had a history of Crohn's disease for 1 to 20 years. All cases resulted in excellent palliation. No patient required a proximal colostomy. These patients have been followed for four months to seven years. Despite severe proctitis in six of these patients at the initial operation, no patient has required a proctectomy. The authors believe this technique achieves adequate palliation and should be employed as the procedure of choice in patients with complex anal fistulas associated with Crohn's disease.