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Diagram 49
9
1
2
8
3
7
4
6
5
109
C A S E
50
Recurrent Crohn’s Disease
Female, 51 Years
History
1971
1978
1981
1996
1997
At 25 years of age resection of Crohn’s
disease of the ileum. Severe diarrhea
continued despite medical treatment.
Resection of terminal ileum (40 cm) for
recurrent Crohn’s disease (Figure 50.1).
Severe diarrhea continued (14–15/day,
3–4 night). Figure 50.1 shows the
involvement of the terminal ileum.
Resection of right colon (25 cm) and
ileum (40 cm) for recurrent Crohn’s
disease associated with large inflammatory mass. Diarrhea continued (8/day,
0/night).
X-ray and colonoscopy evidence of
recurrent disease with marked stricture
formation (Figure 50.2).
The patient remained debilitated with
diarrhea (12–15/day), abdominal pain,
and fever. Resection of ileum (26 cm)
and ascending colon (6 cm) was per-
Figure 50.1: Recurrence in terminal ileum in 1978 after
first resection.
110
1998
2000
(June)
2000
(October)
formed for advanced Crohn’s disease
with stricture formation causing
chronic obstruction. Remaining small
bowel measured 115 cm.
Pyelotomy for renal calculus and
infection.
Diarrhea (12/day), anovaginal fistula
with minor symptoms, managed
conservatively.
Patient described her health as “good”
with minimal symptoms from the
anovaginal fistula. No further follow-up
is available.
Comment
The case illustrates the relentless natural history of
Crohn’s disease over a 30-year period. The four
resections failed to relieve the most troublesome
symptom (diarrhea). Medical therapy was not
helpful. The patient could not tolerate steroids
which caused debilitating candidiasis. Until the last
examination in October 2000, the patient preferred
to manage without anti-inflammatory drug therapy.
Figure 50.2: Colonoscopy (1996) showing recurrent
Crohn’s disease and anastomotic stricture.
Diagram 50
6.30.97
111
C A S E
51
Crohn’s Disease: Strictures of
Ascending Colon and Doudenum
Female, 34 Years
History
Crohn’s disease of the ascending colon was diagnosed in 1984. The symptoms of abdominal pain
and diarrhea were relieved by treatment with prednisolone and sulfasalazine. Five years later, the
patient was suffering from episodes of severe abdominal pain, and investigations revealed a long stricture of the ileum and ascending colon (Figure 51.1)
associated with a large right-sided abdominal mass.
Operation
(5.25.89)
A large mass involving the right colon was firmly
adherent to the anterior abdominal wall and 15 cm
of the adjacent terminal ileum, which was also
affected by the inflammatory process. There were no
Figure 51.2: Recurrent disease with stenosis of the
ileocolic anastomosis indicated by the arrow: March 2000.
Figure 51.1: Demonstrating stricture and spasm of the
terminal ileum and ascending colon prior to right
hemicolectomy in 1989.
112
Figure 51.3: The stricture D2 persists with a further
narrowed segment in D3: May 2004.
Diagram 51
apparent “skip” areas affected in the remainder of
the gastrointestinal tract. A right hemicolectomy
with 20 cm of ileum was performed.
Pathology
The mass measured 10 × 11 cm and was mainly due
to gross thickening of polypoid mucosa, muscle
wall, and pericolic fat in the ascending colon. The
mucosal surface within the stricture was atrophic,
with scars due to previous ulceration. The appendix
was markedly distended due to proximal obstruction of its lumen. There were 4 ulcers in the ileum,
the largest of which extended for 9 cm along the
mucosa. Prominent enlarged mesenteric nodes were
present. The histological changes were consistent
with Crohn’s disease. Two typical granulomas were
found in a lymph node.
Follow-Up
(2004)
At colonoscopy (11.30.89), a dysplastic villous
adenoma (0.9 cm) of the sigmoid colon was removed.
Further colonoscopies were normal until 10 years
and 6 months after resection when a stenosis of the
anastomosis was diagnosed (Figure 51.2). A small
bowel x-ray series demonstrated a stricture of the
second part of the duodenum (0.6 cm in diameter).
This was confirmed on panendoscopy, which
revealed associated inflammation and ulceration.
113
Biopsies showed inflammation not diagnostic
of Crohn’s disease although this diagnosis was
accepted. The patient was treated with prednisolone
for 5 months. Azathioprine and mesalazine were
commenced in 2000 and are current therapy. The
stricture in the second part of the duodenum has
been treated at intervals with balloon dilatation.
Now 15 years since operation, x-rays show persistence of the stricture in the second part of the duodenum and a moderate narrowing in the third
part of the duodenum (Figure 51.3). Colonoscopy
demonstrates persistence of the ileocolic anastomotic stricture. The patient has infrequent bouts of
distention and reflux sometimes accompanied by
vomiting.
Comment
The right hemicolectomy specimen showed active
Crohn’s disease in addition to resolved inflammation, which caused a mass, stricture, and
pseudopolyps. The duodenal disease has persisted
with the development of a second stricture. The
patient’s symptoms at present are not troublesome
enough to justify surgical intervention. The incidence of duodenal involvement in patients with
Crohn’s disease is uncommon. Yamamoto et al have
reported an incidence of 5% in a series of patients
from Birmingham UK.1
5.25.98
For a full-page image of this figure see the appendix.