F. Warren Nugent

Anal complications in Crohn's disease.

Anal fissures, fistulas, and abscesses occurred as complications in 22 per cent of our population of 1,098 patients with Crohns disease. Crohns colitis was much more frequently associated with an anal lesion than Crohns disease of the small bowel (52 per cent vs. 14 per cent). When an anal lesion is the manifesting sign, Crohns disease will soon develop elsewhere in the intestine. Since these lesions frequently herald the onset of intestinal Crohns disease, the physician must always be aware of the possibility of inflammatory bowel disease when dealing with suspicions anal lesions.

Malignant Potential of Chronic Ulcerative Colitis: Preliminary Report

Prior studies confirm the increased incidence of carcinoma of the colon in chronic ulcerative colitis. The authors reviewed clinical and histologic data retrospectively in 23 patients with colon carcinoma and chronic ulcerative colitis. Twenty-two of these patients had dysplasia of colonic epithelium remote from the cancer. The authors prospectively reviewed clinical data and rectal and colonoscopic biopsy specimens on 36 patients with chronic ulcerative colitis, 12 with Crohns colitis, and 12 with miscellaneous disorders. Eight patients with chronic ulcerative colitis had dysplasia; 6 have had colectomy, and 2 of these had carcinoma. No patient without chronic ulcerative colitis had dysplasia. Patients with chronic ulcerative colitis should have periodic rectal and colonoscopic biopsies, and those with moderate to marked dysplasia require colectomy because of the increased risk of colon carcinoma.

Surgical management of Crohn's disease involving the duodenum

The experience with 25 patients who required operation for Crohns disease involving the duodenum is reviewed. Two distinct patterns of duodenal involvement are apparent. Intrinsic duodenal Crohns disease has a characteristic clinical presentation that is distinct from the symptoms seen in patients with involvement of other portions of the gastrointestinal tract. Among 70 patients with duodenal Crohns disease seen over a 30 year period, 22 required surgical intervention at the Lahey Clinic. Although hemorrhage and intractable pain were associated problems in several of these patients, unrelenting duodenal obstruction remained the primary indication for operation. Of patients who underwent operative bypass, 78 percent had a good result with a median follow-up period of 12.3 years. The presence of associated gastric Crohns disease did not influence long-term results. A third of the patients required reoperation for duodenal disease. Marginal ulceration and recurrent gastroduodenal obstruction have been the primary reasons for reoperation. Although the addition of vagotomy to operative bypass has not helped to protect against subsequent marginal ulceration, the absence of appreciable morbidity associated with vagotomy in our series and the high incidence of marginal ulcers reported with gastroenterostomy in other clinical settings lead us to recommend gastroenterostomy with vagotomy as the procedure of choice for duodenal Crohns disease. Proceeding with vagotomy in persons who have had previous ileocecal or extensive small bowel resection should not be undertaken without careful consideration. Similar caution should also be used in patients who are already troubled with poorly controlled diarrhea. The duodenum may also be involved by duodenoenteric fistulas which represent a complication of Crohns disease involving other portions of the gastrointestinal tract. Most frequently this occurs in patients with Crohns colitis who have no evidence of intrinsic duodenal disease. Management of the internal fistula requires resection of the involved colon and closure of the duodenal defect. Three patients with duodenocolic fistula have been so treated.

Urolithiasis as a complication of chronic diarrheal disease

SummaryThe case histories of 761 patients with chronic ulcerative colitis, 300 with regional enteritis, and 39 with ilcocolitis were reviewed. Thirty-five patients formed renal stones during the period of observation, an incidence of 3.18%.The incidence of urolithiasis in regional enteritis was 3.67%; in ileocolitis, 10.3%; and in ulcerative colitis, 2.6%.Excisional surgery of the small or large intestine was associated with an increased incidence of stone formation— 4.44% for regional enteritis, 11.41% for ileocolitis, and 2.92% for ulcerative colitis. Virtually 88.6% of the patients with stones had previously had resection of some part of the small or large intestine.Factors contributing to stone formation in chronic diarrheal disease are: decreased urine volume, increased crystalloid concentration, changes in urinary electrolytes, altered urinary pH, and urinary tract infection.Increased awareness of urolithiasis as a complication of chronic diarrhea, resections of the gastrointestinal tract, and ileostomy should lead to a more accurate assessment of its natural incidence and methods of prevention.

Surgical Aspects of Sclerosing Cholangitis

Of 178 patients with sclerosing cholangitis treated since 1950, 88 patients had associated inflammatory bowel disease, 72 had no such history, and 18 had iatrogenic injury or stone disease. A total of 233 biliary operations were performed, with a 75% rate of temporary improvement after initial operation. Subsequent operations resulted in a lower success rate and a higher mortality rate. Radiologic findings included predominant extrahepatic, intrahepatic, and diffuse disease in 29%, 28%, and 43% of patients, respectively; no survival differences were noted. Seventy-five of one hundred three deaths (73%) were related to liver failure, bleeding, or sepsis. Of 14 patients undergoing portosystemic shunt; 13 died of surgical complications or related disease. Orthotopic liver transplantation was performed in 16 patients and resulted in eight deaths, mainly in patients who had previously, undergone extensive surgical treatment. No survival differences were seen between the patients with inflammatory bowel disease, those, without the condition, or those who had colectomy. Surgical treatment in patients with sclerosing cholangitis should be minimized. Orthotopic liver transplantation should be offered as the treatment of choice for patients with portal hypertension, refractory cholangitis, advanced cirrhosis, or progressive liver failure.

Segmental Pancreatic Autotransplantation with Pancreatic Ductal Occlusion after Near Total or Total Pancreatic Resection for Chronic Pancreatitis: Results at 5− to 54-month Follow-up Evaluation

Reported are eight patients with idiopathic chronic pancreatitis and two patients with alcoholic pancreatitis who had near total distal pancreatectomy for disabling pain and underwent simultaneous segmental pancreatic autotransplantation of the body and tail of the gland to the femoral area in an attempt to prevent or delay the onset of diabetes. The median follow-up period was 31 months, and follow-up study in nine patients ranged from 24 to 54 months. Patency of the grafts was determined by angiography and selected percutaneous venous assays for insulin. Islet cell function was determined by oral glucose tolerance tests, intravenous (I.V.) glucose tolerance tests, and I.V. glucagon stimulation studies. Segmental autotransplantation was technically successful in eight patients, only one of whom required insulin (at 2 years after grafting). The other seven patients with technically successful grafts have remained insulin independent, including two patients who later underwent pyloric preserving pancrcatoduodenectomy for completion pancreatectomy. Variable pain relief was observed in patients who underwent near total pancreatectomy, but pain was unrelieved in those patients who underwent limited distal resection. Patients with idiopathic pancreatitis appear to have better pain relief and preservation of endocrine function than alcoholic patients. Segmental pancreatic autotransplantation prevents or delays the onset of diabetes mellitus and should be considered as an alternative for those patients who require extensive pancreatic resection for chronic pancreatitis.

Micronodular cirrhosis after thiabendazole

SummaryHepatotoxicity secondary to the administration of thiabendazole has been rare since this drug was produced in 1964. In 14 of 15 patients reported previously in the literature, severe intrahepatic cholestasis resolved within seven months of the onset of illness. A recent report documented the progression to cirrhosis in a 15th patient. We report the second case of a patient with intrahepatic cholestasis that developed after treatment with thiabendazole and progressed to severe micronodular cirrhosis.

Clinical course of ulcerative proctosigmoiditis

Ulcerative colitis confined to the rectum or rectum and sigmoid was studied in 234 patients. During a prolonged period of follow-up, these patients had an extremely benign clinical course when compared with that experienced with the diffuse disease. A minimum of morbidity and not a single death occurred. Only 10 patients required operation on the colon for control of disease. Extracolonic manifestations were virtually absent. No malignant degeneration occurred. Although we believe that this disease is part of the spectrum of ulcerative colitis, its anatomic confinement to the distal colon allows prediction of a much more benign clinical course.

Segmental Pancreatic Autotransplantation for Chronic Pancreatitis

Three patients who underwent 95 percent removal of the pancreas for chronic pancreatitis with autotransplantation of the body and tail of the gland to the femoral area are described. The follow-up periods are 18, 6, and 2 months. Pain lessened in all patients and none required exogenous insulin. Patency of the graft was documented in all patients by angiography, technetium scan, and Doppler studies. Percutaneous selective venous assays of both external iliac veins showed a high insulin concentration in the transplanted side, both early and late in the postoperative period. In one patient the operative insulin levels obtained at the completion of autotransplantation proved to be highest in the external iliac vein on the transplanted side, lowest in the iliac vein on the nontransplanted side, and intermediate in the portal vein. Subsequent biopsies of the autografts showed fibrosis of the gland and atrophy of the acinar tissue with preservation of islet tissue. This technique appears to offer a means of preserving endocrine function in selected patients who require extensive resection for chronic pancreatitis.

SERUM LYSOZYME IN INFLAMMATORY BOWEL DISEASE

Serum lysozyme (muramidase) concentrations were measured in three groups of patients: control, ulcerative colitis and proctitis, and Crohns disease. The mean +/-SD for each group was: control, 7 +/- 2; ulcerative colitis and proctitis, 7 +/- 2; and Crohns disease, 10 +/- 4. Although a significant difference was seen between values in patients with Crohns disease and values observed in those with ulcerative colitis or control patients, an important overlap was found between these groups. Further studies are necessary to explain the disparate results between this study and previous reports.