Richard H. Marshak

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.

Granulomatous disease of the intestinal tract (Crohn's disease).

In a landmark lecture on this disease, the author presents his experience with some 8,000 cases of regional enteritis and 4,000 of granulomatous colitis. The paper is divided into sections on the history, pathology, pathogenesis, roentgen findings, and course of the disease. The main thrust of the paper is the extensive roentgen analysis of granulomatous disease, with a discussion of differential diagnosis, especially from ulcerative colitis. Through the years, the author has been impressed with certain clinical and roentgen features of this malady (his Ten Principles of Crohns Disease) which are carefully reviewed.

Segmental infarction of the small bowel.

Impairment of the blood supply to the intestinal tract produces a variety of pathologic changes which may be reflected in roentgen studies. In general, such circulatory disturbances are secondary to strangulating obstructions, as a volvulus or strangulated hernia, or primary, as a result of occlusion of the veins and arteries of the bowel by thrombi or emboli. In the majority of cases, these conditions constitute a surgical emergency requiring prompt intervention. There is a small group, however, in which short segments of small bowel become only partially devitalized instead of undergoing gangrene of the entire wall and perforation. In such an event, healing may occur and be followed by stenosis. The patient may then present the findings of intestinal obstruction of unknown etiology. Barium studies are usually performed for diagnostic purposes, and differentiation from other, particularly neoplastic, causes of obstruction becomes a problem. The purpose of this paper is to describe the roentgen findings i...

Linitis Plastica or Diffusely Infiltrating Type of Carcinoma of the Colon

The linitis plastica type of scirrhous carcinoma occurs most frequently in the stomach and is extraordinarily uncommon in the colon (1, 3, 7) or elsewhere in the gastrointestinal tract (1–3). In a series of 12,000 cases of carcinoma of the colon studied by Fahl, Dockerty, and Judd (2), 11 instances of this type were found, an incidence of less than 1 in 1,000. In an additional 80 cases in that series, scirrhous features were present in the lesion, but the gross appearance was not that of linitis plastica. Many cases reported as the primary linitis plastica type of carcinoma of the colon have been associated with previous long-standing chronic ulcerative colitis. In the series noted above, 3 of the 11 cases occurred in patients with that disease. Strictures due to benign fibrosis in the wall of the colon occur in a number of patients with chronic ulcerative colitis (4) and may perhaps precede the development of a scirrhous carcinoma. Other instances of linitis plastica of the colon originally thought to be...

Granulomatous colitis in association with diverticula.

Abstract Ten patients 45 years of age or older were initially believed, on the basis of clinical and radiologic findings, to have diverticulitis of the sigmoid and descending colon. At operation the same diagnosis was entertained in nine on the basis of the gross findings. Pathological examination of the resected specimens, however, revealed typical lesions of granulomatous colitis. The history, physical examination and laboratory studies did not aid in the differential diagnosis except for the past history of perirectal disease in four patients. Analysis of the radiographic findings, however, revealed some distinguishing features, particularly the presence of a longitudinal, intramural fistulous tract extending parallel to the lumen in the thickened bowel. This finding is pathognomonic for granulomatous colitis.

Diverticulitis of the cecum and right colon: clinical and radiographic features; report of 18 cases.

SummaryEighteen cases of cecal and right colon diverticulitis have been presented. The clinical features, radiologic aspects, and modes of treatment have been emphasized. This series does not support the common concept that most diverticula of the cecum are solitary. The application of careful and repeated barium enema studies and detailed pathologic studies of specimens is urged to elucidate further the nature of cecal diverticula. Factors which may be important in the differential diagnosis with appendicitis have been presented. Conservative nonoperative and operative management is recommended.

The Roentgen Findings in Adenomyosis

Adenomyosis is defined as the heterotopic occurrence of islands of endometrium within the myometrial layer of the uterine wall. Its detailed histopathology was first described by Rokitansky (8) in 1860. Von Recklinghausen (7), in 1896, in a monograph on the subject, identified these endometrial inclusions in the wall of the uterus as misplaced embryonal remnants derived from the mesonephros or wolffian body. Cullen (2), in 1908, utilizing serial sections, demonstrated in 56 of 73 cases studied, an anatomical continuity between the endometrium and the intramural “islands” of endometrial elements. It was subsequently demonstrated that a tubular communication could be identified in all cases provided the adenomyotic glands were located in the inner third of the uterine wall. Where endometrial implants were present in the outer muscle wall, no continuity was demonstrable (1). Pathology The uterus is usually slightly enlarged—in extreme cases to as much as five times its normal weight—in the absence of other d...

Protein-losing disorders of the gastrointestinal tract: roentgen features.

The term “idiopathic” or “essential” hypoproteinemia is used to describe a chronic state characterized by a marked reduction in plasma proteins and by edema without evidence of kidney or liver disease, malnutrition, or other detectable underlying pathological condition. It has been referred to as nephrosis without albuminuria. It appears to be more common in children than in adults, and edema is the chief and often the only sign. All the protein fractions may be reduced or only the albumin may be affected. At autopsy, no lesion can be found to account adequately for the lowered serum albumin. Approximately 40 cases have been reported, which have been carefully studied, but only recently has there been a clue to the etiology. Hypoproteinemia can arise either through reduction in protein synthesis or through excessive loss of proteins. The inadequate synthesis can be due to lack of protein in the diet or to liver disease. Neither of these possibilities occurs in idiopathic hypoproteinemia. Nor is there exce...

Roentgen features of diffuse lymphosarcoma of the colon.

Lymphosarcoma with predominant or sole involvement of the colon is rare (1–3) and the roentgen features of this condition have not been emphasized. As elsewhere in the gastrointestinal tract, lymphosarcoma of the colon occurs in two main varieties: one, a discrete or localized form which presents as a single mass, and the other an extensive diffuse submucosal infiltrating variety extending over long segments of the bowel. Differentiation of the discrete variety from carcinoma on barium-enema examination is difficult but is suggested by dilatation of the lumen of the bowel in concentric fashion at the site of the lesion (Fig. 1, A) or by the presence of a bulky intramural mass with extensive extrinsic involvement (Fig. 1, B). Another discrete type is the endo-exocolonic or dumbbell variety, usually with a considerably larger extrinsic component (Fig. 1, C). There is no difficulty in differentiating the diffuse variety of lymphosarcoma of the colon from carcinoma. The roentgen features are quite characteris...

Multiple Carcinomas of the Large Bowel

Multiple carcinomas of the colon are not uncommon. Sheinfeld recently reviewed the reports of Abell, Cokkinis, Brindley, and Berson and found 30 cases of multiple lesions in 835 cases of carcinoma of the colon and rectum, an incidence of 3.5 per cent. Although our experience would indicate that this figure is quite high, one should keep in mind the possibility of multiple carcinomas when performing a barium enema examination. The following is a report of five carcinomas of the large bowel in one patient. It is noteworthy that there was no evidence of congenital or multiple polyposis. R. C., a white woman, age 42 years, was examined at the office on May 3, 1946. She gave a history of diarrhea developing six years earlier and of alternating diarrhea and constipation since that time. One year before the initial office examination, postprandial cramps occurred, with no relief. Two months prior to the examination she noticed bright red blood in the stool. At that time a barium enema examination performed at an...