Henry D. Janowitz

Perforating and non-perforating indications for repeated operations in Crohn's disease: evidence for two clinical forms.

The surgical indications in 770 patients with Crohns disease undergoing intestinal resection at The Mount Sinai Hospital from 1960-83 have been reviewed. Surgical indications were divided into two principal categories: 375 cases with perforating indications and 395 cases non-perforating. Among 292 patients who underwent second operations for recurrent Crohns disease, the indications for second operation were closely dependent on the indication for primary resection. Second operations were undertaken for perforating indications much more often among cases where the initial indication had been perforating, than among those whose initial indications had been non-perforating (73% v 29%, p less than 0.00001). This trend to similarities in the indications which bring patients to surgery was maintained within each anatomical category of Crohns disease and even between second and third operations (p less than 0.001). Operations for perforating indications were followed by reoperation approximately twice as fast as operations for non-perforating indications, whether going from first to second operation (perforating 4.7 v non-perforating 8.8 years, p less than 0.001), or from second to third (perforating 2.3 v non-perforating 5.2 years, p less than 0.005). Crohns disease thus seems to occur in two different clinical patterns, independent of anatomic distribution. These are a relatively aggressive perforating type and a more indolent non-perforating type, which tend to retain their identities between repeated operations and to influence the speed with which reoperation occurs.

Reoperation and recurrence in Crohn's colitis and ileocolitis Crude and cumulative rates.

To determine the risks of reoperation and clinical recurrence in Crohns disease involving the colon, we analyzed by both crude and actuarial (life-table) methods follow-up data from 160 patients hospitalized with Crohns colitis or ileocolitis from 1964 through 1973. A total of 100 patients (63 per cent) underwent major operation; of these, 58 required reoperation. By the 15th year after initial operation, there was a cumulative reoperation rate of 89 and an overall clinical recurrence rate of 94 per cent. Crude data implied that the reoperation rate diminished with each succeeding operative procedure, from 58 per cent after the first operation to 47 per cent after the fourth. By contrast, actuarial analysis revealed that at the three-year follow-up point, the cumulative chance of reoperation increased from 37 per cent after the first surgical procedure to 60 per cent after the fourth. The inexorable tendency of Crohns ileocolitis to require repeated operations is demonstrable by actuarial methods.

Cancer in Crohn's disease after diversionary surgery: A report of seven carcinomas occurring in excluded bowel☆

Abstract The incidence of bowel cancer was studied in 132 patients who had undergone bypass surgery for Crohns disease and who had been admitted to The Mount Sinai Hospital between 1960 and 1976. Seven patients (5.3 per cent) developed cancer (4 of 63 with ileocolitis and 3 of 69 with ileitis). All seven cancers appeared in excluded loops, four in small bowel and three in colon. Six of the cancers occurred at sites of previous active inflammatory disease and one in a relatively normal “skipped” area of cecum. Four were associated with fistulas: two with enterovesical; one with enterocutaneous; and one with both. In only one case was a tumor mass palpable. All seven patients in this series underwent operation and all showed metastatic spread to liver, lymph nodes, or adjacent organs. All patients died within two years of the diagnostic laparotomy. The mean latent period between onset of disease and appearance of cancer was twenty-seven years, and between bypass surgery and appearance of cancer thirteen years. Four of the seven cancers occurred relatively early, within four years of the bypass procedure, but all seven cases had one feature in common—a long duration of Crohns disease prior to the development of cancer, ranging from seventeen to forty-four years. The diagnosis of cancer in excluded bowel was difficult to make and impossible to confirm prior to laparotomy. Among the large bowel cancers, a preoperative diagnosis was established, by sigmoidoscopy, in only one case. Cancer in a bypassed loop should be suspected in any case of Crohns disease of long duration when a late recrudescence of symptoms occurs, especially when the symptoms are associated with the new appearance of fistula or mass.

Treatment of ulcerative colitis with fish oil n―3-ω-fatty acid : an open trial

We evaluated the efficacy of fish oil n--3-omega-fatty acids, inhibitors of leukotriene synthesis, in the treatment of ulcerative colitis. An open trial of 10 patients with mild to moderate ulcerative colitis who had either failed (n = 9) or refused (n = 1) conventional therapy was performed. Patients received 15 MAX-EPA capsules containing a total of 2.7 g of eicosapentanoic acid in three divided doses daily for 8 weeks. The activity of ulcerative colitis and response to therapy was based upon daily stool diaries, sigmoidoscopy, and symptomatic response. All patients tolerated the fish oil and showed no alteration in routine blood studies. Seven patients had moderate to marked improvement; steroid dose could be reduced in four of the five patients on prednisone. Three patients had little or no improvement. No patient worsened. These results of our open study appear to justify a double-blind trial of this dietary supplement in ambulatory patients with ulcerative colitis.

Amyloidosis and Inflammatory Bowel Disease A 50-Year Experience with 25 Patients

Amyloidosis is a rare but serious complication of inflammatory bowel disease (IBD), especially Crohns disease (CD). It occurred in 15 of our 1709 patients with CD (0.9%) (706 with ileocolitis, 310 with colitis, and 693 with enteritis), but in only 1 of our 1341 patients with ulcerative colitis (UC) (0.07%), admitted to The Mount Sinai Hospital between 1960 and 1985. Eleven of the patients with CD who had amyloidosis had ileocolitis, 2 colitis, and 2 ileitis; these figures represent a frequency within each group of 1.6%, 0.6%, and 0.3%, respectively. Amyloidosis was thus associated 4.4 times more often with CD of the colon than with pure small bowel disease. We have added to this group of 15 patients the 5 cases of CD that were originally reported by Werther et al in 1960, plus another 4 (2 with UC and 2 with CD) who have been seen since 1985, making a total of 25 patients in this series, 22 with CD and 3 with UC. There was a striking male preponderance, 16 of 22, among patients with CD, although 2 of the 3 patients with UC were female. Amyloid disease was diagnosed at a mean age of 40 years, 15 years (range, 1-42) after the onset of CD. Six major forms of amyloidosis occurred: nephropathy, enteropathy, cardiomyopathy, hepatosplenomegaly, thyroid mass, and generalized amyloidosis. Renal disease with proteinurea and/or renal insufficiency occurred in 18 of the 22 patients with CD and in all 3 with UC. Nephropathy was by far the most common lethal manifestation of IBD-associated amyloidosis in this series. Nephrotic syndrome developed in 15 patients with CD and was accompanied by renal failure, the major contributor to mortality, in 10 of the 13 patients who died. Amyloidosis may be associated with suppurative or other extraintestinal manifestations of IBD. Fifteen of the 22 patients with CD who had amyloidosis also had suppurative complications of their bowel disease, although the other 7 had no recognizable suppuration. Extraintestinal manifestations were also common in this series, occurring in 12 of 22 patients with CD and in 2 of the 3 patients with UC; 6 of the 18 patients with nephrotic syndrome also had arthritis. However, there is no evidence that patients with IBD with amyloidosis have extraintestinal manifestations more frequently than do IBD patients without amyloidosis. Earlier reports of amyloid associated with IBD came from autopsy series. In recent years, biopsy has allowed diagnosis to be made during life.(ABSTRACT TRUNCATED AT 400 WORDS)

The plasma amylase: Source, regulation and diagnostic significance

Abstract The total amylolytic activity of the blood appears to be the sum of the activities of several alpha amylases of diverse origin. The salivary glands, pancreas and liver are the likely important tissue sources of the normal blood amylase, although the fallopian tubes, striated muscle and even adipose tissue may possibly contribute in varying degrees. Until methods for specifically labeling the amylase of these tissues are developed this remains conjectural. However, under physiologic conditions the contribution of the pancreas and salivary glands is probably smaller than has been hitherto considered, that of the liver considerably greater. The serum amylase responds quickly and transiently to a variety of substances and hormones which affect carbohydrate metabolism in the liver. As a rough generalization, states of increased carbohydrate utilization are associated with lowered plasma amylase levels. These alterations are not dependent on pancreatic function. In pathologic states of the salivary glands and pancreatic glands, the serum amylase is increased by contributions from these organs. Secretion against obstruction, rupture of ductular apparatus and glandular tissue result in the appearance of variable amounts of amylase in the peripheral blood by way of the venous drainage of the pancreas, and by lymphatic absorption from the peritoneum. Plasma amylase determinations remain the most important laboratory aid in the diagnosis of acute pancreatitis or of acute exacerbations of chronic pancreatitis. The peripheral levels of amylase do not accurately mirror the severity of the pathologic process. Administration of opiates may contribute to the elevation. The role of renal clearance of the enzyme is not completely elucidated. Perforated peptic ulcer and intestinal obstruction with some necrosis of bowel wall may occasionally result in elevated serum amylase levels derived from the peritoneal absorption of enzyme.

Recurrent Regional Ileitis after Ileostomy and Colectomy for Granulomatous Colitis

Abstract In 31 patients clinical, radiographic and pathological evidence of recurrent regional enteritis developed after ileostomy and colectomy for granulomatous colitis (Crohns disease of the colon). These represent at least 46 per cent of all cases of granulomatous colitis treated by ileostomy and colectomy at our institution. Eight required multiple operations, and six had severe nutritional deficits. This high rate of recurrent disease and its frequently serious clinical course contrast with recent claims that such consequences are infrequent. Our observations further underline the need for continued separation of the varieties of inflammatory bowel diseases.

Influence of Glucagon on Pancreatic Exocrine Secretion

Effects of small amounts of glucagon on. pancreatic exocrine function were studied in 7 pancreatic fistula dogs in (a) the resting state, (b) during continuous intravenous infusion of secretin, and (c) during infusion of secretin with pancreozymin. Glucagon produced no significant stimulation of secretion in the resting gland but markedly depressed volume flow and enzyme concentrations in the stimulated gland. Inhibition of enzyme output was greater than was inhibition of volume and bicarbonate output.

Metastatic Crohn's disease.

Cutaneous granuloma formation distant from the gastrointestinal tract in patients with Crohns disease of the bowel has been called metastatic Crohns disease. We report two patients with this entity, including the first to present with an erysipelas-like eruption of the face. A review of the worlds literature reveals that all patients with metastatic Crohns disease have had gastrointestinal disease involving the colon or rectum. Clinical features of the nine previously reported cases are reviewed.

Predicting the Outcome of Corticoid Therapy for Acute Ulcerative Colitis: Results of a Prospective, Randomized, Double-blind Clinical Trial

We looked for factors predicting the therapeutic outcome in 66 patients with severe ulcerative colitis treated with intravenous hydrocortisone or corticotropin (ACTH) for 10 days. Patients were randomized before therapy within strata defined by whether they had received oral corticosteroids continuously before the study (group A, 35 patients) or not (group B, 31 patients). Comparisons were made between groups receiving what we considered optimal corticoid therapy, hydrocortisone for group A and ACTH for group B. Overall, therapeutic success was achieved in 28 (42%), with a median time of 7.5 days. Favorable factors measured on admission to the study were those suggesting less severe colitis activity: absence of fulminant disease, limited disease extent, a shorter duration of the present attack, fewer stools, a lower erythrocyte sedimentation rate (ESR), and a higher hemoglobin. Factors compatible with more severe colitis including fulminant activity, more extensive disease, a shorter total disease duration, bloody stools, and fewer bowel movements, favored an early response among those patients who were to achieve a remission. Prolonging therapy beyond 10 days by switching to the alternate corticoid drug did not improve the remission rate. Achieving remission during the initial therapy period, especially when it occurred early, was the most important predictive factor for a favorable clinical course during the following year. Prolonging therapy did not improve the 1-year remission rate. In fact, a higher proportion of patients who continued to require therapy underwent colectomy than those who received one treatment course.