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Ulceration in Crohn’s Disease of the Small Bowel

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Diagram 49



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1



2



8

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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.



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