Henry Thompson

Natural history of perianal Crohn's disease: Ten year follow-up: A plea for conservatism

A 10 year follow-up of 109 patients with histologic Crohns disease and anal lesions is reported. Fourteen patients (13 percent) have died, 7 from unrelated disorders. Ten required excision of the rectum, but only 5 for perianal disease (4.5 percent). Of the remaining 85 patients, 61 have been followed up to proctoscopy and rectal biopsy. Anal skin tags were still evident in 25 of 37 patients (68 percent), but new tags have appeared in only 2 patients. Ten of 53 fissures (19 percent) were still present at 10 years, and there were no new fissures. Seven of 21 patients (33 percent) still had fistulas but were asymptomatic; the remainder of the fistulas had healed spontaneously (8) or after operation (6). New fistulas have appeared in five patients. None of the patients have been in continent. These results indicate that perianal manifestations of Crohns disease pursue a relatively benign course and are rarely an indication for proctectomy.

Carcinoma in a rectovaginal fistula in a patient with Crohn's disease.

A patient with Crohns disease underwent resection for internal fistulas. Later a rectovaginal fistula developed that persisted with minimal symptoms for 10 years before causing pain and induration in the posterior vaginal wall, due to carcinoma developing within the fistula.

Carcinoma developing in ileostomies after 25 or more years

Primary carcinoma of the ileal mucosa in patients who have had an ileostomy has been documented rarely. This report describes 4 patients seen within the last 4 yr with ileal carcinoma adjacent to the mucocutaneous junction of an ileostomy 25, 29, 30, and 34 yr after the stoma was formed. The incidence of this serious complication may be increasing.

Evaluation of the inflammatory infiltrate in pouchitis with 111In-labeled granulocytes

BACKGROUNDnThe aim of this study was to elucidate the inflammatory infiltrate in pouchitis and define the changes following metronidazole therapy.nnnMETHODSnTwenty-seven patients underwent functional grading, sigmoidoscopic and histological scoring, 111In-labeled granulocyte scanning, and 4-day fecal collections for 111In-labeled granulocyte excretion. Six of the patients with pouchitis underwent repeat studies after 1-month treatment with metronidazole, 400 mg three times daily.nnnRESULTSnThe grade of macroscopic inflammation in the pouch mucosa (sigmoidoscopic score) correlated well with the acute histological score (P < 0.0001), chronic histological score (P < 0.001), 4-hour 111In scan (P < 0.001), 24-hour 111In scan (P < 0.001), and with 4-day fecal 111In excretion (P < 0.001). After metronidazole therapy there was decreased inflammatory grade sigmoidoscopically and histologically on the 4- and 24-hour scans and decreased 4-day fecal 111In granulocyte excretion.nnnCONCLUSIONSnThis study confirms that the inflammatory infiltrate in pouchitis is acute or chronic, is characterized by neutrophils, is usually localized to pouch mucosa, and is always decreased after metronidazole therapy.

Effect of Roux-en-Y biliary diversion on Campylobacter pylori

To assess the effect of biliary diversion on gastric colonization by Campylobacter pylori, we undertook a retrospective histologic study of 24 patients with symptomatic bile reflux after peptic ulcer surgery, who had endoscopic gastric biopsies performed before and after a Roux-en-Y operation. The time interval between the preoperative and postoperative endoscopic examinations ranged from 0.8 to 9.8 yr (mean 4.7 yr). The partial gastrectomy specimen, which had been resected at the initial operation, was available for assessment in 12 patients (50%). Biopsy specimens were assessed for the presence of C. pylori and scored for severity of reflux gastritis by the use of a histologic grading system. Ten of the 12 partial gastrectomy specimens (83%) were C. pylori-positive. Only 13 of the 24 patients (54%) were C. pylori-positive before the Roux-en-Y operation, rising to 22 (92%) after biliary diversion (p = 0.008). The median reflux score was 6 in the partial gastrectomy specimens; it rose to 11 before the Roux-en-Y operation and fell again to 6 after biliary diversion (p less than 0.001). These results suggest that C. pylori may recolonize the gastric remnant after biliary diversion.

Limitations of biopsy in preoperative assessment of villous papilloma

Between January 1975 and December 1979, 58 patients were diagnosed as having villous papilloma of the large howel. A retrospective review was performed and all histologic specimens were re-examined by one gastrointestinal histopathologist (H.T.). On review, 19 (23 per cent) lesions were reclassified as not being villous papilloma. Results of preoperative biopsy examinations were misleading in 13 of the 29 patients who had biopsy procedures reported by any member of the histopathology department. When the assessment of malignancy in the initial biopsy specimens was compared with that of the final histologic diagnosis, there were ten (34 per cent) false-negative and three (10 per cent) false-positive reports. Even when the excised specimens were reviewed for malignancy by a specialist gastrointestinal histopathologist, there were seven (24 per cent) false-negative results.

Perianal ulcer: An unusual presentation of Wegener's granulomatosis

A 46-year-old man, without remarkable past medical history, had a perianal ulcer that appeared spontaneously two months before presentation. At admission, the ulcer was painless, measuring 4 to 5 cm in diameter and showing detachment and a slightly papillomatous aspect at the edge but without induration of the base. Microscopic examination revealed cutaneous ulceration with a well-developed inflammatory response, a few small vessels with intraluminal thrombosis or necrotizing walls, and isolated microscopic granulomata. No infectious disease was detected. The diagnosis of Wegeners granulomatosis was made six months later, when the disease was clinically evident in three principal sites: upper airways, lung, and kidney. At that time, serum antineutrophil cytoplasmic autoantibodies were detected with indirect immunofluorescence microscopy. There has been an excellent response to immunosuppressive therapy. Review of the literature revealed no similar reports.

Beware of Haemolytic Uraemic Syndrome Presenting as Colorectal Disease in Adults

Hemolytic uremic syndrome is seen occasionally by the surgeon in adult patients with colorectal manifestations. Two cases of hemolytic uremic syndrome are presented here, one misdiagnosed clinically as acute appendicitis and the other as acute ulcerative colitis. In each case the diagnosis was only established postoperatively and both patients died of this disease. These cases serve to remind colorectal surgeons that this potentially lethal diseases may occur with symptoms and signs suggestive of more common colorectal pathology.

Screening Procedures for Identifying Patients After Gastric Operations at High Risk of Developing Premalignant Histological Changes

Thirty-six asymptomatic patients at a mean time interval of 12.7 years after gastric surgery were assessed by endoscopy, intragastric pH measurement, and multiple biopsy at a single endoscopy and by99mTc Imino Diacetic Acid (HIDA) scanning for enterogastric reflux: 9 patients had had Polya gastrectomy, 10 patients truncal vagotomy and antrectomy (Billroth I anastomosis), 9 patients truncal vagotomy and pyloroplasty, and 8 patients proximal gastric vagotomy. In the resection group the 9 patients with histological evidence of mucosal risk factors (dysplasia, chronic atrophic gastritis, intestinal metaplasia) had a fasting intragastric pH of more than 4. However, fasting pH was of no value in predicting the occurrence of risk factors after vagotomy (6 of 17 patients). The amount and duration of enterogastric reflux as measured by HIDA scanning over 50 minutes did not correlate with risk factors after resection. The amount and duration of reflux after vagotomy were greater in the patients with risk factors but were not discriminatory. We conclude that HIDA scanning is of little value as a screening procedure and that single sample pH testing is useful only in patients after a gastric resection.RésuméTrente-six opérés ne présentant aucun trouble ont été soumis 12.7 ans en moyenne après leur intervention gastrique à une exploration de routine comprenant: endoscopie, mesure du pH, biopsies multiples lors de lendoscopie et scintigraphie au99mTc HIDA pour apprécier le reflux entérogastrique. Neuf de ces opérés avaient subi une gastrectomie type Polya, 10 une vagotomie tronculaire avec antrectomie (type Billroth I), 9 une vagotomie tronculaire avec pyloroplastie, 8 une vagotomie hypersélective. Chez les sujets qui avaient subi une résection 9 patients qui montraient à lévidence des facteurs de risques au niveau de la muqueuse gastrique (dysplasie, gastrite atrophique chronique, métaplasie intestinale) avaient un pH supérieur à 4 en période de jeûne. En revanche chez les sujets vagotomisés le pH à jeun ne fut daucune valeur pour préjuger de lexistence de facteurs de risques histologiques. La quantité et la durée du reflux entérogastrique appréciée par la scintigraphie pendant plus de 50 minutes ne montra aucune corrélation avec les facteurs de risques chez les sujets ayant subi une résection gastrique. Si la quantité et la durée du reflux chez les patients qui avaient subi une section des vagues furent plus grandes chez les opérés présentant des facteurs de risque, elles ne revêturent pas une valeur discriminatoire. On peut conclure de ces faits que la scintigraphie est une exploration de routine de peu de valeur et que la simple mesure du pH est utile seulement chez les gastrectomisés.ResumenTreinta y seis pacientes asintomáticos fueron evaluados en un tiempo promedio de 12.7 años después de cirugía gástrica mediante endoscopia con múltiples biopsias y medición intragástrica del pH, y por estudio de reflujo enterogástrico con HIDA Tc 99m. Nueve pacientes habían sido sometidos a gastrectomía tipo Polya, 10 a vagotomía troncular y antrectomía (anastomosis Billroth I), 9 a vagotomía troncular y píloroplastia, 8 a vagotomía gástrica proximal. En el grupo resecado los 9 pacientes con evidencia histológica de factores de riesgo en la mucosa (displasia, gastritis atrófica crónica, metaplasia intestinal) exhibieron un pH intragástrico en ayunas superior a 4. Sinembargo, el pH en ayunas no fué de valor para predecir la aparición de factores de riesgo después de la vagotomía (6 de 17 pacientes). La cantidad y duración del reflujo enterogástrico según estudio con HIDA en un período de 50 minutos no mostró correlación con los factores de riesgo que se presentaron después de la resección. La cantidad y la duración del reflujo después de vagotomía fué superior en los pacientes con factores de riesgo, sin llegar a ser una prueba discriminatoria. Nuestra conclusión es que el estudio con HIDA es de valor limitado como un procedimiento de tamizaje y que la sola prueba de pH es de utilidad solamente en pacientes sometidos a resección gástrica.