George B. Rankin

Clinical patterns, natural history, and progression of ulcerative colitis : a long-term follow-up of 1116 patients

We studied the natural history of ulcerative colitis (UC) by following 1116 patients in whom UC had been diagnosed or confirmed at The Cleveland Clinic Foundation between 1960 and 1983. Data before 1973 were obtained retrospectively. Criteria for inclusion in the study were: a diagnosis of UC confirmed by clinical, radiographic, endoscopic, and histologic examination; disease location that could be defined as one of three categories (proctosigmoiditis, pancolitis, or left-sided colitis); and a follow-up of at least five years (mean=12.7 years). Mean age at diagnosis was 32 years. Of the 1116 patients, 46.2% (516) had proctosigmoiditis; 36.7% (410) had pancolitis (colitis of the entire large intestine); and 17.0% (190) had left-sided colitis (from the dentate line to the splenic flexure). Early complications (within two years of diagnosis) included colonic hemorrhage (16.7%) and toxic colitis (12.7%). Complications were highest among patients with pancolitis. Surgery was required for 37.6% of the patients. Primary indications for surgery included chronic or intractable disability (40.2%), fulminating medical failure (16.9%), and colonic dilatation (18.4%). At the most recent follow-up, the disease had extended (progressed to a more serious category) in 53.8% of the patients, although 67.2% were asymptomatic and only 37.0% were on medications. Both the final disease destination and the initial diagnosis impacted cumulative colectomy-ileostomy rates. Factors associated with extension were toxic colitis (P<0.0001); extent of disease at diagnosis (P<0.0001); joint symptoms (P=0.0008); younger age at diagnosis (P=0.06); and severe bleeding (P=0.07).

Surveillance for colonic carcinoma in ulcerative colitis

To evaluate the efficacy of surveillance colonoscopy with biopsy for the detection of high-grade dysplasia (HGD) or colonic carcinoma in patients with chronic ulcerative colitis, we undertook a retrospective review of 248 patients who underwent 370 examinations (mean duration of disease 12 yr). High-grade dysplasia or carcinoma was found in 24 examinations in 16 patients, with a mean duration of disease of 16 yr. There were 15 patients with HGD. Nine patients had HGD alone, 6 had HGD and carcinoma, and 1 had carcinoma without HGD. The overall incidence of HGD was 6%. Dysplasia-associated lesions or mass were the most consistent indicators of carcinoma, the combination being present in four instances. Of the 7 patients with cancer, 6 were recognized by colonoscopy, and 1 patient with negative visual endoscopic findings was discovered using surveillance biopsies. The conclusions of this study are that dysplasia is a reliable histopathologic marker and correlates with the presence of cancer in chronic ulcerative colitis; the absence of dysplasia correlates with the absence of cancer. The presence of dysplasia-associated lesions or mass with HGD is the strongest indication for operation. This study supports the use of surveillance colonoscopy in managing high-risk ulcerative colitis patients.

Extraintestinal and Systemic Manifestations of Inflammatory Bowel Disease

Extraintestinal and systemic manifestations occur commonly in patients with inflammatory bowel disease, specifically ulcerative colitis and Crohns disease, and affect most all organ systems of the body. The occurrence of such widespread manifestations strongly suggests that these disorders are systemic in nature and may have a common mechanism. Extraintestinal manifestations may be incidental findings that cause no symptoms, but more commonly complicate the management of the underlying inflammatory bowel disease, being a source of considerable morbidity and mortality. Some extraintestinal manifestations not only correlate with a specific disease state but also with the location, extent, and degree of activity and disease. Most extraintestinal manifestations found in patients with inflammatory bowel disease involving the small intestine appear to correlate with some underlying pathophysiologic mechanism.

Colonoscopy in the diagnosis of unexplained rectal bleeding.

Three hundred six patients with unexplained rectal bleeding were examined by colonoscopy. Significant lesions were found in 30% including polyps having a diameter of 0.5 cm or larger in 14%, carcinoma in 8%, and a small number of patients with inflammatory bowel disease, vascular formations, and radiation colitis. Colonoscopic findings in a large subgroup of patients with diverticulosis established by barium enema did not differ significantly from those of the group as a whole. Significant lesions were also identified in 22% of small subsets of patients with occult bleeding or unexplained melena.

Congenital duodenal diaphragms in adults: a delayed cause of intestinal obstruction.

Congenital duodenal diaphragms in the adult are uncommon, unsuspected lesions that infrequently cause intestinal obstruction. The diaphragms may be single or multiple and are usually located near the ampulla of Vater. Three cases are summarized and the recent literature reviewed. At least 35 cases have been reported. Treatment most often consisted of duodenotomy, excision of the web and duodenal closure.

Spontaneous improvement of Cronkhite-Canada syndrome in a postpartum female.

SummaryA case report of a 34-year-old female with the Cronkhite-Canada syndrome is presented. The patient developed the characteristic clinical features of intestinal polyposis, skin pigmentation, alopecia, and onychodystrophy which later resolved. An unusual feature was that symptoms developed during the postpartum period. This is the youngest female patient described with the syndrome. The etiology, pathophysiology, clinical manifestations, and management of the Cronkhite-Canada syndrome are reviewed.

Colonoscopy: A report of 644 cases and review of the literature

Abstract Direct vision fiberoptic examination of the colon is time-consuming and the technics are not mastered quickly. Nevertheless, colonoscopy is extremely valuable and perhaps at times an indispensable aid in diagnosis. It can provide accurate information critical to the management of many patients with low morbidity and mortality. For patients who have avoided hospitalization and laparotomy as a result of colonoscopy, there is considerable saving not only of medical costs but also of time lost from work and other duties. This is most obvious in the case of polyp excision. Colonoscopic electrosurgery is emerging as the treatment of choice in a variety of clinical problems and will no doubt gain even wider application as technics and instruments become more sophisticated.

Transmural Colitis: Medical and Surgical Management

Although transmural colitis can be differentiated from the mucosal or ulcerative type with 95% accuracy—a distinction vital to the therapeutic approach—diagnostic error is not uncommon. A patient is presented whose progressive deterioration, originating in early misdiagnosis, eventually required colectomy and ileostomy. Continuous medical supervision is as important after operation as before.

NORMAL MESENTERIC ARTERIOGRAMS IN A CASE OF SENILE ULCERATIVE COLITIS

Ulcerative colitis is principally a disease of persons younger than 50, and the onset of the disease after that age is uncommon. Brown, Gleckler and Jones (1) found only 4 patients more than 50 years old in a group of 106 patients who required surgical treatment. Sloan, Bargen and Gage (2) reported that 158 patients of 2,000 were more than 50 years old, and 44 of 2,000 more than 60 years old when ulcerative colitis developed. Lindner, King and Bolt (3) found that ulcerative colitis developed after the age of 60 in only 6 of 391 patients, and Bockus and associates (4) found it in only 5 of 125 similar patients. When ulcerative colitis occurs after the age of 60 years, careful study of the patient from the viewpoint of unusual etiologic factors, such as amebiasis and specific dysentery organisms, is warranted. Freidman ( 5 ) , in a large series of patients with senile ulcerative colitis, was unable to find a specific cause. Arteriosclerosis and vascular insufficiency are common in the elderly person, and should be considered as possible etiologic factors in senile ulcerative colitis. The pathogenesis of ulcerative colitis remains obscure. Brown (6) found that acute and dramatic emotional crises were the precipitating cause of ulcerative colitis in 7 patients; chronic emotional stress and personality factors may be of even greater importance. Brown and Rankin (7) reviewed the pathogenesis of ulcerative colitis and reported the onset of symptoms of ulcerative colitis in 3 patients after routine enemas. In 1956 the association of ulcerative colitis and lupus erythematosus in 2 patients was reported by Brown, Shirey and Haserick (8), and since then we have seen 4 additional patients with both diseases. The uncommon but definite association of ulcerative colitis and lupus erythematosus, and the rare coexistence of ulcerative colitis and periarteritis nodosa have raised the question as to whether or not the vascular changes are etiologic. Studies of the vascular changes in ulcerative colitis have been limited. McAllister and associates (9) catheterized the mesenteric arteries in vivo during operation under anesthesia in 5 patients, and also in vitro in the resected specimens from 12 patients with ulcerative colitis. They reported increased vascularity, tortuous vessels, and vessels showing right-angled branching. However, the followjng factors cannot be excluded: 1) the vascular spasm and other changes induced by the anesthesia, 2) the trauma of laparotomy in the in vivo studies, and 3) the trauma of resection in the in vitro studies. Young and associates (10, 11) reported 8 patients, and others reported 34 additional patients in whom intestinal ischemia developed after abdominal

Cancer Surveillance in Ulcerative Colitis

The purpose of this study was to determine if colonoscopic surveillance for the detection of dysplasia is an appropriate approach to assess the risk of development of colonic cancer in patients with long-standing ulcerative colitis.