William A. Hawk

Clinical patterns in Crohn's disease: a statistical study of 615 cases.

Results of a study of 615 consecutive patients with Crohns disease seen at the Cleveland Clinic from 1966 through 1969 are reported. The thesis evaluated was that initial anatomic involvement bears directly on the clinical course and prognosis. The following clinical patterns were established: (1) ileocolic, 252 patients (41%); (2) small intestine, 176 patients (28.6%); (3) colon, 166 patients (27%); (4) anorectal, 21 patients (3.4%). Among symptoms, statistically significant features (P

Indications for Surgery in Crohn's Disease: Analysis of 500 cases

Data for 500 patients with Crohns disease who underwent operations were analyzed (316 patients, 1966 to 1969; 184 patients, 1972 to 1973) by comparison of various anatomic disease locations (clinical pattern): (1) ileocolic, 225 patients; (2) small intestinal, 130 patients; (3) colonic, 127 patients; (4) anorectal, 18 patients. Indications for surgery were tabulated and compared using statistical analysis for the three large patterns. For patients with ileocolic Crohns disease, the primary surgical indications were internal fistula and abscess, 44%, intestinal obstruction, 35%, and perianal disease, 12%. For patients with Crohns disease of the small intestine, the primary surgical indications were intestinal obstruction, 55%, and intestinal fistula and abscess, 32%. Patients with colonic Crohns disease had a significantly more diverse surgical indication, with poor response to medical therapy, 26%, internal fistula and abscess, 23%, toxic megacolon, 20%, and perianal disease, 19%. These values were highly statistically significant (P less than 0.0001) in all instances but one. This study demonstrates that statistically significant differences occur in the surgical indication depending on the location of Crohns disease. Patients with ileocolic, small intestinal, and colonic involvement have striking differences in clinical course. It is concluded that Crohns disease is not a homogeneous entity, but should be recognized as having a varying course depending on clinical pattern.

Myofibroblastic contraction in spontaneous regression of multiple congenital mesenchymal hamartomas.

Subcutaneous nodules from a newborn boy with “multiple fibromatosis” involving the head, neck, trunk, and all four extremities were studied by light microscopy, transmission electron microscopy, and immunofluorescent techniques. Light microscopy suggested a hamartomatous process with fibroblastic, adipose, vasoformative and apparent smooth muscle components. The principal cell population combined ultrastructural characteristics of both fibroblasts and smooth muscle cells. Immunofluorescent studies revealed binding of human anti‐smooth muscle antibody to the cytoplasm of the spindle cell population of the subdermal nodules but not to fibroblasts of the overlying uninvolved skin. The ultrastructural and immunofluorescent studies revealed the previously undescribed fact that fibrous hamartoma of infancy is principally a proliferation of myofibroblasts. At age 8 months, there was complete spontaneous regression of all subcutaneous nodules not previously altered by excisional biopsy. The authors conclude that myofibroblasts are fibrocontractile cells, which play a role in shrinkage and eventual disappearance of these subdermal hamartomas.

Primary myocardial disease. Correlation with clinical findings, angiographic and biopsy diagnosis: Follow-up of 139 patients

The purpose of this study was determination of the prognostic value of clinical and tissue (biopsy) findings of 139 patients with cardiomyopathy. The types of cardiomyopathy were congestive (113 patients) and hypertrophic or constrictive (26 patients). The mean follow-up period of all patients was 4.3 years. Follow-up of the survivors was between 13 months and 11.9 years, mean 5.4 years. Of the 47 cardiac deaths (33.8%), the minimum and maximum follow-up was two weeks and 7.5 years, respectively (mean 2.1 years). Patients with congestive heart failure had the highest five year cardiac mortality rate (51.8%). Coexisting cardiac arrhythmia had no influence on prognosis and an arrhythmia only was benign in most patients. Myocardial hypertrophy or fibrosis or both and myocardium with no pathologic diagnosis had prognostic value. Small-vessel disease was infrequent and not associated with specific clinical manifestations.

The advantages of subtotal thyroidectomy and suppression of TSH in the primary treatment of papillary carcinoma of the thyroid

Patients between the ages of 6 and 45 years with distant metastases from papillary carcinoma of the thyroid can be treated as effectively by subtotal thyroidectomy and suppressive doses of thyroid hormone as by total thyroidectomy followed by treatment with iodine 131 (131I). Moreover, distant metastases can be treated by either 131I or suppression as effectively after they are apparent on x‐ray as they can be when treated in a subclinical stage. Therefore, in patients younger than 45 years old it is rarely necessary to perform a total thyroidectomy or to do frequent postoperative scans. In patients older than 44 or younger than 7 who have distant metastases or extensive involvement of both lobes, total or almost total thyroidectomy is justified if it can be done with minimal morbidity. In patients of this age group whose tumors fail to respond to suppressive doses of thyroid, 131I should be used. In view of the importance of diagnostic related groups (DRG) to the economy of hospitals, we note that the cost of total thyroidectomy, ablation by 131I, and intermittent body scans is at least three times that of less radical procedures which, in conjunction with suppression by thyroid feeding, give the same survival with less morbidity.

The Structural Study of the Saphenous Vein

From November, 1971, to September, 1974, 1,179 patients received aortocoronary saphenous vein bypass grafts at the Cleveland Clinic Hospital. Segments of saphenous vein from each patient were sent for microscopical analysis. These vein segments were classified as normal or abnormal (phlebosclerotic). Four hundred ninety-six normal vein grafts in 295 patients were restudied and had a patency of 87.9%. One hundred forty-four abnormal vein grafts in 86 patients were restudied and showed 89.5% patency. This study suggests that histopathological identification of an abnormal (phlebosclerotic) vein segment does not constitute a determining factor as far as late patency is concerned in a vein segment that is not grossly sclerotic.

Carcinoma associated with mucosal ulcerative colitis, and with transmural colitis and enteritis (Crohn's disease).

Among 1,500 patients with inflammatory disease of the colon and small intestine at the Cleveland Clinic in the past 15 years, 40 have been found to have carcinoma of the colon or small intestine. All records have been reviewed with regard to histologic classification of disease, and clinical correlation. Of these, 37 had carcinoma of the colon accompanying mucosal ulcerative colitis, one had carcinoma and transmural colitis, and two with long‐standing transmural (regional) enteritis had carcinoma of the ileum. The factors associated with the development of cancer in ulcerative colitis are: 1. Presence of mucosal disease—very rare in transmural disease; 2. Duration of colitis—average 18 years in this study; 3. Activity of disease—all but one had active, chronic symptoms, and 4. Extent of disease—all but one had total colonic involvement. It is concluded that the mucosal type of ulcerative colitis should be considered potentially malignant.

Villous tumors of the duodenum and jejunum. Report of four cases and review of the literature.

Three cases of villous tumors of the duodenum and one case of villous tumor of the jejunum are reported, and the literature of villous adenomas of the small intestine is reviewed. The clinical manifestations of villous adenomas of the small intestine are nonspecific gastrointestinal complaints, intestinal bleeding, intestinal obstruction including intussusception, and biliary tract involvement with obstructive jaundice. Roentgenographic study of the upper gastrointestinal tract will confirm the diagnosis in most instances. In the absence of evidence of malignancy, simple excision or a limited resection is the effective treatment.

Carcinoma Associated with Regional Enteritis Report of 2 Cases

SummaryDespite an increasing incidence of carcinoma associated with ulcerative colitis, carcinoma accompanying regional enteritis of the small intestine and/or colon is rare. We have found that only 17 cases of carcinoma of the small intestine associated with regional enteritis have been reported previously; we have reported 2 cases seen at the Cleveland Clinic. Each patient had a relatively long history of regional enteritis with symptoms referable to intermittent, incomplete obstruction of the small intestine. Both patients underwent operation because of increasing intestinal obstruction. The rarity of carcinomas of the small intestine makes it appear that the association is more than simple coincidence.

Percutaneous Myocardial Biopsy of the Left Ventricle Experience in 198 Patients

A thin-walled Silverman needle has been used for 254 percutaneous punch biopsies of the left ventricle in 198 patients with closed chests at the Cleveland Clinic. The technic is described. The biopsy specimens were adequate for diagnosis in 192 patients. In all but three patients (who had lupus erythematosus, scleroderma, and chronic glomerulonephritis with congestive heart failure) cardiac catheterization and selective cardioangiographic studies were performed. There was angiographic evidence of primary myocardial disease, coronary atherosclerosis, or both, or rheumatic valvular disease in 175 patients. Cardiac catheterization and angiographic studies demonstrated no evidence of organic heart disease in 20 patients.Cardiac tamponade was a complication of myocardial biopsy in eight patients. Post-pericardiotomy syndrome occurred in four patients and ventricular fibrillation in one patient.Myocardium with no pathologic diagnosis and interstitial fibrosis or myocardial hypertrophy or both were the light microscopic findings in 165 patients. Representative sections of the biopsy in 27 patients demonstrated small-vessel disease, basophilic degeneration, focal interstitial myocarditis, amyloidosis, Aschoffs nodules, or vacuolar degeneration. The current experience suggests that myocardial biopsy combined with selective cardioangiography is of experimental value, improves the accuracy of diagnosis, and plays a role in the management of some patients.