Ian P. Todd

Hirschsprung's disease and idiopathic megacolon in adults and adolescents.

The distinction between Hirschsprungs disease and idiopathic megacolon in childhood dates from the classic clinical, radiological, and histological studies of Bodian, Stephens, and Ward. This article describes clinical experience over 15 years of 94 patients in whom megacolon of these two types was recognised for the first time after the age of 10, to illustrate the problems of diagnosis and treatment in later years. Just as it is now recognised that patients with the clinical characteristics of Hirschsprungs disease may have one of several abnormalities of the myenteric plexus, including not only absence of ganglion cells, but also patchy or zonal loss, abnormal neurones or neuronal dysplasia, so idiopathic megacolon may also be a heterogeneous group of cases. This paper suggests on clinical grounds that those patients with idiopathic megacolon whose symptoms start in childhood differ from those whose symptoms develop in later years.

Internal fistulas in Crohn's disease.

There is doubt about the timing of surgery for patients with internal fistulas in Crohns disease. Although immediate operative intervention for all patients has been advocated, such a policy has not always been followed at St. Marks Hospital. Between 1971 and 1982, 83 internal fistulas were identified in 59 patients with Crohns disease. Fifty-nine fistulas arose primarily from the small intestine and involved another segment of the bowel, five were between large bowel and duodenum, and three between areas of large bowel. Sixteen fistulas (ten from ileum and six from large bowel) involved the bladder. Thirty-six patients with 54 fistulas underwent immediate surgical treatment. Fifteen patients with 20 fistulas required surgery later. There was one postoperative death among the 51 patients treated surgically and one late death unrelated to the treatment of the fistula. Of the remaining 49 surgically treated patients, 46 were traced and remain well, six after further surgery. Eight patients with nine fistulas (four involving the bladder) were treated at St. Marks without operation. One later required surgery elsewhere for an enterocutaneous fistula, but the remaining seven patients are well. This study suggests that the presence of an internal fistula, even if it involves the bladder, is not an absolute indication for immediate surgery and that the severity of the symptoms should dictate the treatment policy.

Chagas disease of the colon and rectum

Chagas disease is a rare condition in patients anywhere but in Central and Latin America. This case is therefore reported because the patient was born in Britain and spent only a short time in an area where Chagas disease is endemic. It is believed that this patient is the first case of Chagas disease to be treated in Britain. Chagas disease causes a generalized degeneration of autonomic ganglia and usually presents as megaoesophagus or megacolon. The disease may also cause the heart to enlarge followed by cardiac failure.

Psoas abscess and Crohn's disease.

The transmural inflammatory process characteristic of Crohns disease of the bowel predisposes to the formation of intestinal fistulae both internal and external. Sinus tracts can penetrate to other parts of the bowel, bladder, perineum, umbilicus and anterior abdominal wall, while posteriorly the retroperitoneal space could be involved, such as the psoas sheath leading to psoas abscess formation. Thirty years ago psoas abscess was virtually synonymous with tuberculous disease of the spine or sacroiliac joints. Today reports indicate that Crohns disease is an important cause of psoas abscess, tuberculous disease having been largely mastered (Kyle 1971). We report a case of recurrent psoas abscess in a patient with severe Crohns disease.