Proctitis after fecal diversion in Crohn's disease and its elimination with reanastomosis: implications for surgical management. Report of four cases

Diverting the fecal stream has been considered to affect the course of Crohn's disease favorably. Adverse effects on the distal segment have not previously been distinguished from clinical signs and symptoms. The course of four patients with Crohn's disease who underwent fecal diversion with an in situ rectum were observed in whom sigmoidoscopy was initially normal at the time of the diversion, became distinctly abnormal during the year after the diversion, and then returned to normal within 3 mo following reestablishment of intestinal continuity. The entity of nonspecific diversion proctitis might account for this phenomenon independently or by accelerating the Crohn's disease process. The inflammation present was nonspecific and did not show the stigmata of Crohn's disease. Continuity of the intestinal tract should be maintained in the course of Crohn's disease surgery if feasible. If a diversion is clinically warranted, reanastomosis should be considered as early as possible despite evidence of inflammation in the rectal mucosa.     

Diversion colitis in Crohn disease. A case report and review of the literature

A 45 year old man, suffering from Crohn's disease of the colon, and a 25 year old woman, with ileocolitis Crohn, developed a diversion colitis in the remaining distal segment of the colorectum after ileostomy. After reanastomosis, which was done 11 and 2 years later, the diversion colitis vanished spontaneously. This case report and the data in literature indicate the opinion, that reanastomosis of the distal colon should be done early after diversion, if there are no specific signs of Crohn's disease in the remaining colorectum.     

Diversion colitis: histological features in the colon and rectum after defunctioning colostomy.

Diversion of the faecal stream by ileostomy or colostomy leads to inflammation in the defunctioned segment, known as diversion colitis. The affected bowel is rapidly restored to normality by reanastomosis. Diversion colitis should not be mistaken for inflammatory bowel disease, for which reanastomosis would be inappropriate. Studies of biopsy material from patients with diversion colitis have shown a variety of histological features, but no consistent pattern. The histology in resection specimens of defunctioned large bowel from 15 patients with no pre-existing inflammatory bowel disease was studied. Nine patients had symptoms of abdominal pain or rectal discharge of blood or mucus that developed between 9 months and 17 years after diversion procedure. The histology was abnormal in all. Findings were similar in 14 patients, regardless of the duration of faecal diversion, and comprised diffuse mild chronic inflammation with or without mild crypt architectural abnormalities, crypt abscesses, or follicular lymphoid hyperplasia. One patient had more severe changes, resembling active ulcerative colitis. These features in biopsy specimens are unlikely to be diagnostic but should provide useful information in avoiding a mistaken diagnosis of inflammatory bowel disease in these patients.     

Predictability of the postoperative course of Crohn's disease

Eighty-nine patients who had been treated by ileal resection for Crohn's disease between 1979 and 1984 were included in a prospective cohort follow up to study the natural course of early postoperative lesions. Recurrent lesions were observed endoscopically in the neoterminal ileum within 1 year of surgery in 73% of the patients, although only 20% of the patients had symptoms. Three years after surgery, the endoscopic recurrence rate had increased to 85% and symptomatic recurrence occurred in 34%. The ultimate course of the disease was best predicted by the severity of the early postoperative lesions, as observed at ileoscopy. Clinical parameters that influenced outcome were preoperative disease activity, the indication for surgery, and the number of surgical resections. When patients were stratified for preoperative disease activity, the severity of lesions found at endoscopy remained a strong predictive factor for symptomatic recurrence. In 22 other patients submitted to "curative" ileal resection and ileocolonic anastomosis, the segment to be used as neoterminal ileum was carefully examined during surgery, and two large biopsies were taken before making the anastomosis. An ileoscopy was performed 6 months after surgery. Although all patients had a macroscopically normal neoterminal ileum and 19 had entirely normal biopsies at the time of surgery, 21 patients were found at ileoscopy to have developed ileitis involving a 15-cm segment (range, 4-30 cm), and 20 had unequivocal microscopic lesions on biopsies. These studies suggest that early lesions in the neoterminal ileum after Crohn's resection do not originate from microscopic inflammation present in this bowel segment at the time of surgery. The early postoperative lesions in the neoterminal ileum seem to be a suitable model to study the pathogenesis of Crohn's disease and also to evaluate new therapeutic modalities, either to prevent development of these early lesions or to treat progressive recurrence.     

The Role of Sigmoidoscopy and Rectal Biopsy in Diagnosis and Management of Inflammatory Bowel Disease: Personal Experience

Conventional sigmoidoscopy and rectal biopsy are very useful in the diagnosis, differential diagnosis, and management of inflammatory bowel disease. The rectal biopsy is particularly important in establishing the diagnosis of Crohn's disease when the rectal mucosa is grossly normal. The sigmoidoscopy and biopsy serve to assess the response to medical therapy in inflammatory bowel disease and are important adjuncts to colonoscopy in surveillance for dysplasia and carcinoma in patients with ulcerative colitis. Sigmoidoscopy is quick, requires no preparation, is cost effective, and the biopsies are extremely safe with the use of the cupped bronchoscopic forceps.     

Pathology of the defunctioned rectum in ulcerative colitis.

Faecal stream diversion may induce inflammatory changes in the defunctioned segment of the large intestine. These changes are predominantly mucosal, although confusing histological features including granulomas may be present. The pathology of 15 defunctioned rectal stumps has been studied. All patients had previously undergone urgent total colectomy for ulcerative colitis and rectal stumps had been left in situ while they awaited pelvic ileal reservoir construction. All rectal stumps showed predominantly mucosal disease but there were additional features such as florid lymphoid follicular hyperplasia (12 cases), transmural inflammation (nine cases), granulomas (four cases), fissures (eight cases), and changes akin to ischaemia or to pseudomembraneous colitis (four cases). These changes may result from a combination of defunctioning and of active ulcerative proctitis. Some induce a histological appearance that may mimic Crohn's disease. Nevertheless review of all 15 colectomy specimens showed unequivocal ulcerative colitis and none of the patients has subsequently shown any clinical, radiological, or pathological evidence to support a diagnosis of Crohn's disease. Histology of the rectal stump in ulcerative colitis may lead to an erroneous diagnosis of Crohn's disease and the patient may subsequently be denied the advantage of a pelvic ileal reservoir.     

Endoscopic appearances of the rectal mucosa of patients with Crohn's disease visualised with a magnifying colonoscope.

The magnified endoscopic appearances of the rectum are described in 12 patients with Crohn's disease with apparent rectal sparing on sigmoidoscopy. Five of them had minor abnormalities on colonoscopy but the remaining seven had a normal rectum. After the application of 0.2% methylene blue, examination using a magnifying endoscope (Olympus CF-HM) revealed characteristic 'worm-eaten' appearances in 75% of the patients regardless of the activity of their disease. Histological examination of biopsy specimens from these lesions showed marked inflammatory changes, and granulomas or microgranulomas were found in 75%. Inflammatory changes were not seen in mucosa which appeared normal on magnifying colonoscopy although microgranuloma were found in three cases. These observations confirm the focal nature of Crohn's disease and may suggest that the early lesions are mucosal and frequently contain granulomata.     

Scanning electron microscopy of rectal mucosa in Crohn's disease

Rectal biopsies from healthy control subjects, and from patients with Crohn's disease whose rectal mucosa appeared normal by sigmoidoscopy and light microscopy, were examined by scanning electron microscopy. Appearances within both groups were quite variable, and no clear differences between the groups could be distinguished.     

Endoscopic and histological patchiness in treated ulcerative colitis

OBJECTIVE: Traditionally, contiguous distribution of inflammation (endoscopic and histological) with rectal involvement is thought to be important in distinguishing ulcerative colitis (UC) from Crohn's disease of the colon. Little long-term data are available that prove whether this rule holds during the course of disease as it is modified by time and treatment. The aim of this study was to investigate the prevalence of endoscopic and histological patchiness and rectal sparing in treated UC over time and to correlate these findings with treatment at the time of endoscopy. METHODS: Patients with well-established UC who underwent sequential colonoscopy or flexible sigmoidoscopy with biopsies were included in this study. Patients' medical records including endoscopy/biopsy reports and clinical status/symptoms/treatment at the time of endoscopy were reviewed retrospectively. RESULTS: A total of 32 patients (14 men, 18 women; median age, 45 yr; median UC duration, 15 yr) underwent 175 sequential endoscopies with biopsies (161 colonoscopies, 14 sigmoidoscopies; median, five endoscopies per patient; range, 3-10). Endoscopic and/or histological patchiness was present in 20 of 175 (11%) sequential endoscopies with biopsies over time from 12 of 32 (38%) patients. Endoscopic and/or histological rectal sparing was present in 27 of 175 (15%) of sequential endoscopies with biopsies over time from 14 of 32 (44%) patients. Seven patients had both patchiness and rectal sparing. Therefore, in 47 (27%) follow-up endoscopies in 19 (59%) patients, there was either patchy disease, rectal sparing, or both sometime during the course of disease with treatment. There was no significant difference in treatment, including steroid use and rectal therapy, between those with patchiness and/or rectal sparing and those without. CONCLUSIONS: Contrary to traditional teaching, endoscopic and histological patchiness of inflammation and rectal sparing are common during the course of disease in treated UC and seem to be unrelated to specific therapy.     

Prolyl hydroxylase activity in serum and rectal mucosa in inflammatory bowel disease.

Prolyl hydroxylase activity in rectal mucosa was found to be significantly greater in 11 patients with Crohn's disease than in 11 control subjects with the irritable bowel syndrome and 16 patients with ulcerative colitis (P less than 0.005). Seven of the patients with Crohn's disease had a histologically normal rectum. This abnormality in apparently normal mucosa supports the concept that Crohn's disease is a 'continuous' disease of the gastrointestinal tract. Although there was no significant difference in prolyl hydroxylase activity between control subjects and patients with ulcerative colitis, those patients with quiescent disease tended to have lower values than those with active mucosal inflammation. Prolyl hydroxylase activity could not, however, be detected in the sera of either healthy control subjects or patients with inflammatory bowel disease.     

Factors predictive of persistent or recurrent Crohn's disease in excluded rectal segments

The fate of the excluded rectal segment after surgery for Crohn's colitis remains poorly defined. To determine prognostic factors relating to the fate of the rectal segment, records of 47 patients who underwent creation of an excluded rectal segment were studied. Disease developed in 33 patients (70 percent) in the excluded rectal segment by five years; 24 patients (51 percent) had completion proctectomy by 2.4 years; and 9 patients (19 percent) retained a rectum with disease at a median follow-up period of five years (range, 2–13 years). At a median follow-up time of six years (range, 2–21 years), 14 patients were without clinical disease. The three groups were equivalent with respect to sex, duration of preoperative disease, indication for operation, distribution of disease, and histologic involvement of the proximal rectal margin. The median age of patients in the proctectomy group at diagnosis tended to be younger than that of patients with a retained excluded rectal segment (22, 30, and 31 years for patients having proctectomy, patients with a diseased excluded rectal segment, and patients with a normal excluded rectal segment, respectively). Neither initial involvement of the terminal ileum nor endoscopic inflammatory changes seen in the rectum predicted eventual disease of the excluded rectal segment. However, initial perianal disease complicating Crohn's colitis was predictive of persistent excluded rectal segment disease and often required proctectomy. Therefore, because the presence of perianal disease and Crohn's colitis predicts persistent or recurrent excluded rectal segment disease, primary total proctocolectomy or early completion proctectomy may be indicated in this subgroup of patients.Read at the meeting of The American Society of Colon and Rectal Surgeons, Boston, Massachusetts, May 12 to 17, 1991.     

Rectal potential difference and histology in Crohn's disease.

The rectal potential difference (PD) was measured in 27 patients with Crohn's disease, and in 16 subjects without gastrointestinal disease to establish a normal range. Sigmoidoscopic assessment and rectal biopsy were performed in all patients with Crohn's disease, and the mean resting rectal PD was significantly reduced in patients with sigmoidoscopically active disease and in those with abnormalities of the superficial epithelium on rectal biopsy. Patients with diarrhoea had a significantly lower mean resting PD than those with normal bowel habit, suggesting that an abnormality of rectal sodium transport may be contributing to the diarrhoea in these patients. The response of rectal PD to mineralocorticoid stimulation with oral fludrocortisone was measured in 13 patients. The PD failed to rise only with patients with sigmoidoscopically active disease, and the test proved to be a less sensitive indication of minor mucosal abnormalities than sigmoidoscopy of biopsy.     

Late onset Crohn's disease in patients with colonic diverticulitis

Summary and Conclusions Twenty-five patients had Crohn's disease in a colonic specimen resected for presumed diverticulitis. A syndrome of combined diverticulitis and Crohn's colitis is presented, which is heralded by anotectal disease, rectal bleeding, and fistulas. The illness is characterized by multiple operations, failure of diversionary procedures to control distal disease, and a high incidence of lethal pelvic sepsis. Results of these patients' studies suggest that late onset Crohn's colitis should be considered when clinical diverticulitis is present associated with anorectal disease (past or present), rectal bleeding, fistulas, or exceptional difficulty with an initial resection for diverticulitis. Patients with persistence of disease after colonic resection, distal recurrence after diversion, or late fistulization after resection for diverticulitis should be considered to have Crohn's colitis until proved otherwise. Also, patients requiring multiple resections for clinical diverticulitis are also strongly suspect for Crohn's colitis. When significant anorectal disease is present and Crohn's colitis is either proved or suspected, proctocolectomy may be warranted. Read at the meeting of the American Society of Colon and Rectal Surgeons, Atlanta, Georgia, June 10 to 14, 1979     

Immunoglobulin containing cells in inflammatory bowel disease of the colon: a morphometric and immunohistochemical study.

Immunoglobulin containing cells in rectal and sigmoid colonic mucosa in endoscopically obtained biopsies from 10 patients with ulcerative colitis and 10 patients with Crohn's disease were studied, using an indirect immunoperoxidase technique. These findings were compared with the immunoglobulin containing cell number in colonic biopsies from 10 control patients with no evidence of colitis. In biopsies from the 20 patients with inflammatory bowel disease a marked increase in area of the lamina propria per millimetre mucosa length was found. In ulcerative colitis a marked increase in number of IgG containing cells was observed. In Crohn's disease the increase in IgG containing cell number is dependent on the degree of activity of inflammation. In quiescent of active Crohn's disease of the colon we found a significant increase of the IgM containing cells. The number of IgM containing cells per millimetre mucosa length will differentiate the pathology of Crohn's disease from ulcerative colitis.     

Multicenter,multiyear study of safety and efficacy of flexible sigmoidoscopy during pregnancy in 24 females with follow-up of fetal outcome

Our objectives were to analyze the risks versus benefits of flexible sigmoidoscopy to the pregnant female and fetus. We retrospectively studied 24 consecutive pregnant patients admitted to four university hospitals during seven years who underwent 26 flexible sigmoidoscopies. Sigmoidoscopy indications included hematochezia in 11, diarrhea in 12, abdominal pain in 7, constipation in 2, and occult rectal bleeding in 1. Seven patients were in the first trimester of pregnancy, nine were in the second trimester, and eight were in the third trimester. Sigmoidoscopy provided helpful clinical information in all patients. Twelve patients had a lesion diagnosed by sigmoidoscopy, including reactivation of Crohn's colitis, reactivation of ulcerative colitis, infectious colitis, nonspecific colitis, bleeding internal hemorrhoids, pseudomembranous colitis, anastomotic ulcer, and newly diagnosed Crohn's colitis. In particular, nine of 11 patients with rectal bleeding had a lesion identified by sigmoidoscopy. No endoscopic complications occurred to any pregnant female. Two pregnant patients underwent repeat sigmoidoscopy without complications. Fetal outcome was ascertained in all but one pregnancy. Eighteen pregnant females delivered healthy infants (16 at full term, two at 35 or 36 weeks). Their mean Apgar scores were 8.8±0.4sd at 1 min, and 9.0±0.4sd at 5 min. One diabetic and hypertensive female suffered an involuntary abortion nine weeks after sigmoidoscopy, which appeared unrelated to the sigmoidoscopy. Four pregnancies were voluntarily aborted. This study suggests that flexible sigmoidoscopy does not induce labor or result in congenital malformations, that sigmoidoscopy is not contraindicated during pregnancy, and that sigmoidoscopy should be considered in medically stable pregnant patients with significant gastrointestinal bleeding. Sigmoidoscopy should be performed with maternal monitoring by electrocardiography and pulse oximetry and possibly with fetal monitoring, after obstetrical consultation and after stabilization of vital signs. Medical stabilization may require transfusion of blood products and supplemental oxygen administration.     

Is Hartmann's procedure safe in Crohn's disease?

INTRODUCTION: Crohn's disease-associated colorectal cancer may occur in an area of defunctioning bowel. Some patients with Crohn's colitis undergo subtotal colectomy, ileostomy, and low Hartmann's procedure in an effort to preserve the rectum. This procedure has also been advocated for patients with severe anorectal Crohn's disease, in whom nonhealing of the perineal wound after proctectomy occurs with alarming frequency. The authors present a review of the literature and three cases of cancer developing in the defunctioning rectal stump despite surveillance proctoscopy. METHODS: Twenty-five patients underwent low Hartmann's procedure for severe anorectal Crohn's disease. Surveillance proctoscopy was performed as follow-up. Development of cancer in the rectal remnant or anus or recurrence of symptoms was managed by resection and adjuvant therapy. RESULTS: One patient developed squamous-cell carcinoma of the anal canal, underwent resection and adjuvant therapy, and was disease free at the time of this study. Two patients developed adenocarcinoma of the rectum. Both underwent resection and adjuvant therapy. One patient died and the other developed a recurrence. CONCLUSIONS: The authors recommend interval perineal proctectomy in all patients undergoing low Hartmann's procedure for severe anorectal Crohn's disease in whom rectal preservation is not possible. Regularly scheduled interim surveillance proctoscopy performed every two years, with biopsies of macroscopically normal-appearing and abnormal-appearing rectal mucosa and curetting of fistulous tracts, is also recommended to decrease the possibility of missing occult malignancies.     

Are superficial lesions of the distal part of the ileum early indicators of Crohn's disease in adult patients with abdominal pain? A clinical and radiologic long term investigation.

The possibility of early superficial Crohn's disease should be considered when mucosal irregularities without transmural abnormalities are seen in the distal 15 cm of the ileum in young patients with protracted symptoms of abdominal pain and diarrhoea. Radiologic assessment of the small bowel is improved using the barium/air double contrast technique and in this study mucosal abnormalities were categorised as a 'mucosal nodularity pattern', an 'abnormal mucosal fold pattern', and a 'specks of barium pattern'. None of the 21 patients followed prospectively for four to seven years developed established criteria for Crohn's disease, or any other chronic progressive disease of the small bowel. Colon examinations were normal. In comparison 26 patients with histologically proven Crohn's disease of the ileum were studied retrospectively and no similar clinical or radiologic characteristics were present. It is concluded, therefore, that such isolated superficial lesions are not pathognomonic and are not early indicators of Crohn's disease or any other chronic progressive disease of the small bowel.     

Crohn's Disease in Endoscopic Biopsies of the Gastric Antrum and Duodenum

Forty-five patients with Crohn's disease in whom the upper gastrointestinal tract was normal by x-ray were examined by gastroduodenoscopy. Biopsies were analyzed histologically from the lower esophagus, body of the stomach, gastric antrum and duodenal bulb. Cell counts were made of 500 connective tissue cells of the duodenal mucosa. Histological examinations and cell counts of the duodenal mucosa were also performed on 50 healthy volunteers used as controls.
Histological lesions were found in 19 Crohn's disease cases; 11 (24%) were considered pathologically diagnostic and all these were found in the antrum or duodenum. In 11 the mucosa was endoscopically normal. Granulomas were present in three cases (7%), all from normal appearing mucosa. Microscopic alterations of the antrum and duodenum, similar to findings in the normal appearing rectal mucosa, support the concept that Crohn's disease involves the entire alimentary canal and that lesions are seen grossly only where the disease is most advanced.     

Outcome of ileorectal anastomosis for Crohn's colitis

One hundred thirty-one patients underwent ileorectal anastomosis (IRA) for Crohn's colitis. Preoperatively, 84 patients (63 percent) were found to have mild or moderate proctitis and 47 (37 percent) had rectal sparing. Sixty-eight (52 percent) had associated small bowel disease, and 20 (15 percent) had perianal disease. Sixty-five IRAs were performed at the time of subtotal colectomy, while 56 were done after previous surgery. Anastomotic leaks occurred in four patients. There were no operative deaths. Thirteen patients (10 percent) with protecting stomas never underwent closure. Among the remaining 118 patients with functioning IRAs, 30 (23 percent) required later proctectomy and 16 (13 percent) required proximal diversion, with the mean period with a functioning IRA in these 46 patients being 4.1 years (range, 6.2 months–12.7 years). An additional 13 patients required preanastomotic resection and neo-IRA, and 11 required proximal small bowel resection. The mean duration of function of all 118 IRAs was 9.2 years. At the time of review, after a mean follow-up of 9.5 years, 72 patients (61 percent) retained a functioning IRA, with 44 being free of disease, while 28 were being treated with steroids or antidiarrheal medication. The mean stool frequency was 4.7 per day. In patients with Crohn's colitis, IRA should be considered as an alternative to proctocolectomy if the rectum is not severely diseased and sphincter function is not compromised.Read at the meeting of The American Society of Colon and Rectal Surgeons, Boston, Massachusetts, May 12 to 17, 1991.     

Vaginal fistulas in Crohn's disease

Twenty-eight patients with vaginal fistulas complicating Crohn's disease, seen between 1970 and 1987, are described. Twelve required early operation; five of them had rectal excision. Conservative management was used in 16 patients but in none of these did the fistula close spontaneously. Subsequent proctocolectomy was required in seven patients though two patients with high vaginal fistulas were managed by total colectomy, end ileostomy, and oversewing of the rectal stump. Only two high fistulas resulting from ileal Crohn's disease resolved with resection and anastomosis of the diseased segment alone. Local repair was unsuccessful despite repeated operations in two of five patients. Two patients died of malignancy arising within a chronic vaginal fistula. Although some vaginal fistulas complicating Crohn's disease cause little disability and can be managed symptomatically, they do not heal by conservative therapy or by a proximal defunctioning stoma alone. In time, severe bowel symptoms develop in the majority of patients and necessitate proctectomy.