Crohn's disease of the appendix

Crohn's disease limited to the appendix is uncommon. Clinically, it is likely to mimic acute appendicitis. It is more frequent in young people and definitive diagnosis is histological. We present a series of seven cases of Crohn's disease of the appendix that were treated in our surgery service over the past 12 years. The seven patients had pain in the lower right quadrant. In all patients, the preoperative diagnosis was acute appendicitis and appendectomy was performed. Histopathological evaluation was required for diagnosis. In the postoperative course, one patient was diagnosed with colonic Crohn's disease, and outcome was favorable with medical treatment. Although isolated Crohn's disease of the appendix is a rare entity, it should be considered in the preoperative differential diagnosis of patients with right lower quadrant pain and a protracted preoperative course mimicking acute appendicitis. Disease recurrence elsewhere in the alimentary tract is uncommon.     

Intestinal carcinoma in Crohn's disease. Report of four cases and review of the literature

BACKGROUND: Increasing numbers of intestinal carcinomas in patients affected by Crohn's disease have been reported by several authors, even if the strength of this associations (age, longstanding of the disease, its characteristics and distribution) still has to be elucidated. METHODS: From January 1992 to July 2000, 130 patients with Crohn's disease were submitted to surgery. RESULTS: Four patients showed an associated intestinal carcinoma at operation, in 3 cases located in the ileum, and in 1 case in the colon. Patients' mean age was 54 years. Mean duration time of the Crohn's disease was 7 years. One patient died 3 months after surgery for disseminated peritoneal carcinomatosis, whereas 3 patients are still alive with malignancy free at 5, 8, and 11 years after the tumor resection. CONCLUSIONS: These results suggest the difficulty in recognizing patients with Crohn's disease who are at risk for intestinal carcinoma. Longstanding disease, previous intestinal exclusion surgery, enterocutaneous or other types of fistulas should be considered for the development of cancer. Therefore, the prognosis may be good if early diagnosis and treatment are made.     

克罗恩病102例临床分型及术式选择

目的探讨克罗恩病(Crohn's disease,CD)的临床类型与术式选择。方法回顾性分析33年来经外科治疗的102例CD患者的临床资料,分别行小肠部分切除术71例,结肠部分切除造口术4例,回肠部分切除造口术3例,小肠结肠短路手术4例,内瘘行小肠及结肠部分切除、吻合术4例,回肠穿孔修补术3例,肠粘连松解术6例,腹腔脓肿引流术并小肠造口术4例,结肠癌根治术3例。结果本组术前确诊48例,误诊54例,误诊率52.9%。根据发病缓急程度、病理变化及临床表现特点,分为急性阑尾炎型、慢性肠炎型、肠梗阻型、腹腔肿块型、腹膜炎型、出血型、肠瘘型、中毒性巨结肠及癌变型。手术缓解或有效90例(88.2%),11例出现术后并发症,死亡3例。结论CD临床类型多种多样,采用相应的术式是手术成功的关键。     

Crohn's disease limited to the appendix.

BACKGROUND: Crohn's disease confined to the vermiform appendix is rare. In our study, the incidence was 0.2% of all patients diagnosed with Crohn's disease at La Paz University Hospital, Madrid, Spain, in 20 years. METHODS: Here we review the clinical records of 10 patients with isolated appendiceal Crohn's disease. RESULTS: Preoperative diagnosis was acute appendicitis in all 10 cases, and all patients underwent appendectomy. Postoperative complications were limited to an enterocutaneous fistula in 1 patient. There was no evidence of recurrence during a mean follow-up period of 14.5 years (range 2 to 25 year). CONCLUSIONS: We conclude that Crohn's disease when confined to the appendix is less aggressive than in other sections of the intestine, with a low recurrence rate and incidence of postoperative fistula.     

Crohn disease: results of a series of 42 intestinal resections

Forty-two patients underwent a resection for acute or chronic complications of Crohn's disease during the years 1983-1987. The colon was involved in 38% (16 patients), the small bowel in 31% (13 patients) and the ileocaecal region in 31%. In small bowel disease, the indication for operation was either an intestinal obstruction or an internal abscess. In colonic locations, poor response to medical therapy was the indication for operation in 10 patients (63%), and an acute complication in the remaining cases. The operations performed were always "radical resections": 13 resections of small bowel, 13 ileocaecal resections, 7 ileocolectomies with ileosigmoidostomies, 6 ileocolectomies with ileorectostomies, 2 left side hemicolectomies with colorectostomies and one total coloproctectomy. There was no operative mortality. A post-operative complication occurred in two patients (4.8%). The recurrence rate was 12% after 30 months average follow up in the 34 patients with only one operation for Crohn's disease. There was no second recurrence in the 8 patients operated for a first recurrence. The factors affecting recurrence after resection were: a short pre-operative time interval since first clinical symptoms: 4.6 years versus 5.3 years without recurrence (p less than 0.01); the colonic location of the Crohn's disease (p less than 0.02). Colonic location rate of the disease was found to be higher in this study as compared to others. Since "radical resection" fails to cure all patients, surgery should be restricted to acute on chronic complications.     

Acute intestinal obstruction as an initial presentation in Crohn's carcinoma

A 40 years old female patient presenting with symptoms of acute intestinal obstruction was diagnosed as a case of adenocarcinoma superimposed on Crohn's disease. The diagnosis, as happens in most of these cases, was established post-operatively on the basis of histopathological examination. Acute intestinal obstruction due to adenocarcinoma in Crohn's disease as an initial presentation is very uncommon especially in this geographical area where Crohn's disease in itself is an uncommon disease entity.     

Surgical treatment of Budd-Chiari syndrome induced by Behcet's disease.

OBJECTIVE: Although Budd-Chiari syndrome in Japanese is usually chronic, and of unknown etiology and idiopathic, Behcet's disease is rare as an underlying disorder of Budd-Chiari syndrome in Japanese. To clarify the Behcet-induced Budd-Chiari syndrome, the clinical course and pathologic findings of patients with Behcet-induced Budd-Chiari syndrome were compared with those of patients with idiopathic Budd-Chiari syndrome. PATIENTS AND METHODS: We treated 45 patients (15 women and 30 men) with our devised surgical procedure. With normothermic partial bypass, the occluded vena cava and hepatic veins were reopened. The age of the patients ranged from 24 to 76 years (mean, 48.9 13.0 years). In two patients, Budd-Chiari syndrome was induced by Behcet's disease (Behcet group). The other 43 patients (control group) had no distinct underlying disorder. The Behcet group was compared to the control group with regards to (1) onset of symptoms and duration of illness prior to medical treatment, (2) preoperative laboratory data including liver function, (3) intraoperative findings, (4) microscopic findings of liver tissue, and (5) postoperative course. RESULTS: (1) In the Behcet group, duration of illness from diagnosis to surgical treatment was markedly shorter (P=0.027, 8.5 months vs. 10.1 10.6 years). (2) The preoperative laboratory data of liver function were similar in both groups with moderately impaired hepatic function. (3) The Behcet group had no patent hepatic vein (P=0.025 vs. 1.22 0.57). (4) Microscopic examination of the liver tissue showed liver cirrhosis or liver fibrosis in the control group, and centrilobular marked congestion only in the Behcet group. (5) During hospitalization, one patient of the control group died due to preoperative severe hepatic failure. One patient with Behcet's disease underwent reoperation due to reocclusion by Behcet-induced vasculitis, and the other died of peritonitis by intestinal Behcet's disease. CONCLUSION: In Budd-Chiari syndrome in Japanese, the Behcet-induced Budd-Chiari syndrome had an acute clinical course, and its postoperative prognosis depends on the prognosis of the Behcet's disease.     

Abdominal abscesses in adolescents with Crohn's disease

Little information is available about the development of abdominal abscesses in adolescents with Crohn's disease. We report the clinical presentation of five adolescents with Crohn's disease who developed this complication. The mean time from diagnosis until development of an abdominal abscess was 1.7 years. The admitting diagnosis was an acute abdomen in two patients and recurrent Crohn's disease in the other three. No features of the clinical presentation or laboratory data distinguished this group from other adolescents with Crohn's disease. The use of ultrasound and CT scanning was helpful in making this diagnosis preoperatively. Those patients with active Crohn's disease who do not respond promptly to medical therapy should be evaluated for the development of this complication.     

Risk factors for surgery and postoperative recurrence in Crohn's disease

OBJECTIVE: To assess the impact of possible risk factors on intestinal resection and postoperative recurrence in Crohn's disease (CD) and to evaluate the disease course. SUMMARY BACKGROUND DATA: The results of previous studies on possible risk factors for surgery and recurrence in Crohn's disease have been inconsistent. Varying findings may be explained by referral biases and small numbers of patients in some studies. METHODS: Data on initial intestinal resection and postoperative recurrence were evaluated retrospectively in a population-based cohort of 1,936 patients. The influence of concomitant risk factors was assessed using uni- and multivariate analyses. RESULTS: The cumulative rate of intestinal resection was 44%, 61%, and 71% at 1, 5, and 10 years after diagnosis. Postoperative recurrences occurred in 33% and 44% at 5 and 10 years after resection. The relative risk of surgery was increased in patients with CD involving any part of the small bowel, in those having perianal fistulas, and in those who were 45 to 59 years of age at diagnosis. Female gender and perianal fistulas, as well as small bowel and continuous ileocolonic disease, increase the relative risk of recurrence. CONCLUSIONS: Three of four patients with CD will undergo an intestinal resection; half of them will ultimately relapse. The extent of disease at diagnosis and the presence of perianal fistulas have an impact on the risk of surgery and the risk of postoperative recurrence. Women run a higher risk of postoperative recurrence than men. The frequency of surgery has decreased over time, but the postoperative relapse rate remains unchanged.     

Distant processing of pancreas islets for autotransplantation following total pancreatectomy.

BACKGROUND: Small duct chronic pancreatitis is associated with intractable pain and failure to thrive, usually unresponsive to conventional management approaches. Total pancreatectomy is considered after failure of medical intervention. The major morbidity following total pancreatectomy is diabetes mellitus with its associated complications. This adverse outcome can be mitigated through autotransplantation of islets recovered from the pancreatectomy specimen. This approach has been limited historically owing to the absence of an on-site islet processing facility. We present the results from 5 pancreatectomized patients whose islets were prepared 1,500 miles away. METHODS: Five patients (4 women, 1 man, average age 42 years) who failed medical therapy and were not candidates for longitudinal pancreaticojejunostomy underwent total/completion pancreatectomy (4 total, 1 completion) for intractable symptoms from idiopathic small duct chronic pancreatitis. The resected pancreata were preserved in ViaSpan solution and were transferred to an islet processing laboratory by commercial airliner and returned. The dispersed pancreatic islet tissue was infused into a portal vein tributary through an operatively placed catheter after systemic heparinization. RESULTS: All 5 patients experienced complete relief from pancreatic pain; 2 had significant residual discomfort from underlying Crohn's disease. Three of the 5 patients had minimal or no insulin requirement after autotransplantation (median follow-up of 23 months); 1 patient continued with glycemic control difficulties related to Crohn's disease. One patient died 17 months following autotransplantation from an unrelated pneumonia. CONCLUSION: Total pancreatectomy with autologous islet transplantation can offer patients with idiopathic small duct chronic pancreatitis pain relief without the sequelae of diabetes mellitus and can be performed without an on-site islet processing facility. All patients undergoing total/ completion pancreatectomy should be considered candidates for this procedure.     

妊娠期急性胰腺炎：单中心20年52例分析

目的：总结妊娠期急性胰腺炎（APP）的发病特点和预后及20年的变迁,探讨其临床诊治要点。 方法：回顾性分析近20年（1994—2013年）中南大学湘雅医院收治的52例APP患者的临床资料。 结果：52例APP中,孕早期3例（5.8%）,孕中期12例（23.0%）,孕晚期37例（71.2%）;轻型胰腺炎26例（50.0%）,中度重症胰腺炎13例（25.0%）,重症胰腺炎13例（25.0%）。病因方面：高脂血症性胰腺炎28例（53.8%）,胆源性14例（27.0%）,特发性胰腺炎10例（19.2%）。全组孕产妇病死率为0;胎儿病死率为19.2%（10/52）,其中2例胎死宫内,4例早产后新生儿窘迫,4例因考虑药物对胎儿影响而行流产或引产。 结论：近20年APP的发病率呈逐年上升趋势,且多数发生于孕晚期,高脂血症和胆道疾病是其主要病因,其中前者所占比例尤为突出。APP仍伴有较高的胎儿病死率,进一步规范的治疗和加强围产期新生儿的护理对于改善APP总体预后具有重要价值。     

Diagnostic peritoneal lavage in acute pancreatitis--the value of microscopy of the lavage fluid

In only 2 of 98 cases with a clinical diagnosis of acute pancreatitis submitted to peritoneal lavage in order to assess severity was the diagnosis found to be wrong. These two cases (one was biliary peritonitis and the other mesenteric infarction) were not differentiated from severe pancreatitis by clinical examination, measurement of plasma amylase, the appearance of the lavage fluid or its amylase or white cell count. One case was exceptional in that the lavage fluid had a faecal odour, and both cases were found to have large numbers of intestinal organisms which were clearly visible on routine microscopy. Scanty commensals (? contaminants) were seen in the lavage fluid of 2 of the 96 patients with acute pancreatitis but no intestinal organisms were found. If peritoneal lavage is used in the management of acute pancreatitis, microscopy of the lavage fluid, carried out as an emergency investigation, might help to detect the occasional case with a false diagnosis.     

Evaluation of intestinal mucosal permeability function in patients with acute pancreatitis

This study aims to evaluate the intestinal mucosal permeability in patients with acute pancreatitis. The lactulose:mannitol (L:M) ratio was used to assess permeability. It is an inexpensive and quite reliable method. The intestinal permeability was increased in patients with acute pancreatitis compared with the controls. In addition, patients with severe pancreatitis had higher intestinal barrier dysfunction compared with patients with mild pancreatitis, the L:M ratio being .2 and .029, respectively. It was also concluded that the permeability increased gradually over the course of pancreatitis and was maximum at day 7 (P < .01). This provides a window of opportunity for therapeutic intervention to prevent the late observed increase in intestinal permeability.     

克罗恩病合并肠瘘273例临床特征与预后分析

目的 分析克罗恩病（CD）合并肠瘘病人的临床特征及预后状况。方法 回顾性分析2001年1月至2015年6月南京大学医学院附属金陵医院就诊的CD合并肠瘘的273例病人资料，分析其临床特征、肠瘘特点、临床用药方案及预后转归。结果 273例病人中，男女比为2.5:1；起病年龄为29（22，40）岁；确诊年龄为31（25，42）岁；起病至确诊的间隔时间为22（8，31）个月；最常见的首发症状分别为腹痛（78.0%）、腹泻（28.9%）及发热（26.0%）；确诊时最常见的发病部位为末端回肠（56.8%）；确诊时最常见的发病性质为穿透性病变（54.9%），其次为狭窄（42.1%）、无狭窄无穿孔（2.9%）及肛周病变（19.0%）。共并发肠瘘442例次，其中肠外瘘有327例次（73.9%），最常见的类型为回结肠吻合口瘘124例次（28.1%），肠内瘘有115例次（26.1%），其中肠膀胱瘘38例次（8.6%）。肠内（91.9%）及肠外（72.9%）营养联合柳氮磺胺吡啶（57.9%）及雷公藤多苷（48.0%）是治疗此类病人的最为常用的方法；共有227例（83.1%）病人行抗感染治疗，β-内酰胺类（77.6%）及硝基咪唑类（56.0%）是最常用药物。所有入选病人共接受外科手术625例次，确诊后1、3及5年的累积手术率分别为34.4%、59.0%及63.0%。共有9例（3.3%）病人在随访期间死亡，确诊后1、3、10年的累积存活率分别为98.5%、97.8%和96.7%。
结论 与西方及其他亚洲国家文献资料相比，该中心CD合并肠瘘病人在性别比、发病部位、手术率及死亡率等方面均存在一定差异，尚须继续进一步随访及深入研究。     

重症急性胰腺炎病程与外科治疗

目的:总结外科手术在重症急性胰腺炎(severe acute pancreatitis,SAP)治疗中的作用.方法:对47例SAP病程演变中外科手术治疗情况作回顾分析.结果:病程第一期行手术10例,主要是解除胆道梗阻,降低腹内高压,引流胆汁及腹腔渗液;第二期行手术5例,主要是清除胰腺坏死组织、引流脓液;第三期行手术32例,主要是胰、肠瘘的确定性手术及防止胰腺炎再发的胆囊切除术.总治愈率为85.1%(40/47),总病死率为14.9%(7/40).死亡原因:休克3例,ARDS并急性肾功能衰竭2例,腹腔及后腹膜感染合并霉菌感染致MOSF 2例.结论:外科手术在SAP治疗中仍具重要地位,但手术原因和方式因病期不同而有所不同.     

Acute pancreatitis in elderly patients. Pathogenesis and outcome

Forty patients over 70 years of age with acute pancreatitis were studied. The most common cause of pancreatitis was biliary tract disease (14 patients, 35 percent). Twelve patients (30 percent) were discharged with a diagnosis of idiopathic pancreatitis, but tests such as endoscopic retrograde cholangiopancreatography that might have established the cause of disease were frequently not employed. Eight of the 40 patients died, for a mortality rate of 20 percent. Significant morbidity occurred in an additional seven (17.5 percent). Multisystem failure was the cause of death in all eight patients, and only two patients with multisystem failure survived. The mortality rate was significantly higher in those patients with postoperative pancreatitis. Acute pancreatitis in the elderly carries a grave prognosis. All patients should undergo thorough evaluation, as biliary tract disease is the most common cause. Cholecystectomy should be performed in those with biliary disease to prevent recurrent attacks.     

A prospective study to determine the efficacy of antibiotics in acute pancreatitis.

This study is a double "blind" prospective evaluation of the efficacy of antibiotics (Ampicillin) in the treatment of acute alcohol-induced and idiopathic pancreatitis. Fifty-eight patients with acute pancreatitis were randomly divided into antibiotic and non-antibiotic treatment groups. The two groups were comparable clinically at the onset of the study and other than for antibiotics received identical therapy. The patients without antibiotics had a clinical course equal or slightly more favorable than the antibiotic treatment group in all parameters examined. These data indicate that prophylactic use of Ampicillin is not indicated in patients with routine acute alcohol-induced or idiopathic pancreatitis. The role of prophylactic antibiotics in patients with pancreatitis related to biliary calculi and those with more severe varieties of acute hemorrhagic or necrotizing pancreatitis remains to be more clearly defined.     

Lethal pancreatitis: a diagnostic dilemma.

Clinical and pathological information from forty patients who died with pathologically severe acute pancreatitis was correlated. Patients were classified into four etiologic groups: those with biliary pancreatitis (11 patients), alcoholic pancreatitis (13 patients), idiopathic pancreatitis (10 patients), and renal failure (6 patients). Antemortem diagnosis was made in only 57 per cent of the patients studied. The diagnosis was determined before death in 91 per cent of the biliary patients but in none of the renal patients. Thirty-seven patients died from their first clinical attack of pancreatitis. Operation in patients with biliary pancreatitis failed when biliary decompression was not provided. Peripancreatic sepsis was a frequent lethal mechanism in patients with biliary pancreatitis, but renal and respiratory failure were more common in patients with alcoholic pancreatitis.     

Pediatric Crohn's disease

This paper reviews our 10 year clinical experience (1974 to 1983) with 33 patients with Crohn's disease; eight were diagnosed during the first five years and 25 during the second five years of the review. There were only 10 patients with ulcerative colitis during this period. The median age of diagnosis was 13 years, range 6 to 16 years. The main presenting clinical features were abdominal pain (29 patients), weight loss (26 patients), and diarrhea (23 patients). The method of diagnosis included radiological investigations and fiberoptic endoscopy with biopsy. The colon was involved in 20 patients. The therapy included Salazopyrine, steroids, parenteral nutrition (11 patients) including home parenteral nutrition (seven patients) and surgery (13 patients). Significant weight gain was observed in patients after intestinal resection. There were no deaths. We conclude that the incidence of pediatric Crohn's disease appears to be increasing, is more common than ulcerative colitis, and requires surgical treatment in a high proportion of patients. In our experience these patients respond well to aggressive nutritional therapy including home parenteral nutrition and carefully selected surgical treatment.     

Pancreatographic findings in idiopathic acute pancreatitis

Background/purpose Despite extensive evaluation based on clinical history, biochemical tests, and noninvasive imaging studies, the cause of acute pancreatitis cannot be determined in 10 to 30% of patients, and a diagnosis of idiopathic acute pancreatitis is made. The purpose of this study was to clarify the pancreatographic findings in patients with idiopathic acute pancreatitis.Methods Endoscopic retrograde cholangiopancreatography (ERCP) was performed in 34 patients with idiopathic acute pancreatitis, and the pancreatographic findings were examined. Patency of the accessory pancreatic duct was examined by dye-injection endoscopic retrograde pancreatography (ERP) in 16 of the 34 patients.Results In 11 patients (32%), the following anatomic abnormalities of the pancreatic or biliary system were demonstrated: complete pancreas divisum (n = 5), incomplete pancreas divisum (n = 2), high confluence of pancreaticobiliary ducts (n = 2), choledochocele (n = 1), and giant periampullary diverticulum (n = 1). Pancreatographic findings were normal in 17 patients. Eleven of these patients were examined by dye-injection ERP, and all were found to have nonpatent accessory pancreatic duct.Conclusions Anatomic abnormality of the pancreatic or biliary system is one of the major causes of idiopathic acute pancreatitis. Closure of the accessory pancreatic duct may play a role in the development of idiopathic acute pancreatitis in patients with a normal pancreaticobiliary ductal system.