Perforating and nonperforating Crohn's disease. An unpredictable guide to recurrence after surgery.

Four hundred eighty-six patients who have had resections for Crohn's disease at the Cleveland Clinic were reviewed. The patients were categorized by indication for surgery into three groups: perforating (P) (135 patients), nonperforating (NP) (278 patients), and miscellaneous (M) (77) patients. One hundred ninety-four patients had two or more resections and 56 underwent a third resection. Patients were no more likely to have the same indication for surgery at the time of the second resection (P = 25 percent; NP = 44 percent; M = 57 percent) or the third resection (P = 11 percent; NP = 65 percent; M = 55 percent). There was also no difference in the interval between resections for the P and NP groups. The lack of agreement between resections suggests that the categorization of patients into P and NP groups does not facilitate prediction of the nature of recurrent disease. The concept of aggressive perforating and indolent nonperforating Crohn's is not substantiated by this study.

The long-term outcome in Crohn's disease.

The long-term outcome of Crohn's disease was reviewed in 139 patients who were treated at the Cleveland Clinic for a minimum of 15 years. At the time of diagnosis, 38 (27 percent), 39 (28 percent) and 62 (43 percent) patients had small-bowel, large-bowel, and ileocolic patterns of disease, respectively. The disease progressed with time and, eventually, 104 (75 percent) patients had ileocolic disease. One hundred twenty-two patients (88 percent) underwent at least one definitive operation for the disease. Forty-four (32 percent) patients had proctocolectomies and 65 (47 percent) have ileostomies. Associated manifestations of Crohn's disease occurred in a high proportion of patients; perianal disease in 78 (56 percent), intestinal fistulas in 45 (32 percent), extraintestinal disease in 49 (35 percent). Six patients died of causes directly related to the disease. Specific complications tend to occur at definite times in the course of the disease. Crohn's disease is not a benign condition. There is a relentless progression of the disease and a high incidence of complications when patients are followed over a long period.

Role of the faecal stream in the maintenance of Crohn's colitis.

The role of the faecal stream in the maintenance of the inflammation in Crohn's disease has been studied. Small bowel effluent and a sterile ultrafiltrate of it were reintroduced into the defunctioned colon of patients with Crohn's colitis treated by split ileostomy. The systemic effect of these challenges on the patients was assessed clinically and by laboratory tests, and the effect on the local disease was assessed by endoscopy, histology, and quantitative analysis of lamina propria plasma cell populations. There was little response to the ultrafiltrate challenge. In contrast the clinical responses to challenge with ileostomy effluent were marked in some patients. One patient relapsed and eight others had clinically detectable responses. On the other hand changes in laboratory, endoscopic, histological, and morphometric tests in response to the faecal challenge were less pronounced. The only significant changes in the laboratory results were a relative lymphopenia (p less than 0.05) and a raised ESR (p less than 0.02) after seven days challenge with the effluent. The plasma cell density also increased but not significantly. In conclusion, these results suggest that factors greater than 0.22 microns in the faecal stream are responsible for the maintenance and exacerbation of inflammation in Crohn's disease.

Peroral pulsion intubation of malignant esophageal strictures using a fiberoptic technique.

Palliative peroral pulsion intubation of malignant esophageal strictures in 44 patients with incapacitating dysphagia is reviewed. Intubation, using a fiberoptic endoscope, the Nottingham introducer, and a modified Celestin tube was performed, usually under intravenous sedation. Intubation was successful in 93 per cent and provided satisfactory relief of dysphagia. Six deaths (14%) were the result of intubation, three from esophageal perforation, two from aspiration pneumonia, and one from hemorrhage. The overall hospital mortality was 23 per cent. Six patients required reintubation for proximal or distal migration of the prosthesis. Although mean survival was short (3.2 months), esophageal intubation by this technique is relatively safe, minimizes hospitalization, and offers reasonable palliation in most patients.

Split ileostomy and ileocolostomy for Crohn's disease of the colon and ulcerative colitis: a 20 year survey.

The clinical course of 140 patients who have had a split ileostomy for ulcerative colitis or colonic Crohn's disease over a 20 year period is reported. In 37 patients with ulcerative colitis there was no sustained improvement. In the 102 patients with Crohn's disease there was an immediate clinical improvement in 95, which was sustained in 65. Thirty patients have subsequently required a proctocolectomy for persistent inflammation, and 28 are still defunctioned. Bowel continuity was restored after 61 split ileostomies and in 44 patients intestinal continuity remains intact at the present time (mean follow up since closure = 62.5 months, range 0-231 months). It is concluded that a split ileostomy is a safe conservative operation producing at least temporary improvement in severely ill and malnourished patients with Crohn's colitis, and that if a subsequent resection becomes necessary it may be less extensive than was thought applicable at the initial operation. In 27 patients a resection has not been required.

The effect of split ileostomy on perianal Crohn's disease.

The effect of 32 split ileostomies on 29 patients with severe symptomatic perianal Crohn's disease is reported. The perianal disease improved or healed after 23 (72 per cent) split ileostomies, although it relapsed in 2 patients while diverted and in 6 after closure of split ileostomy. Seven of 12 rectovaginal fistulas healed initially but only remained healed in those patients without rectal involvement with disease. At the time of review 6 patients have normal bowel continuity, 8 have had proctocolectomies and 15 are still defunctioned. Split ileostomy should be considered as an initial step in the management of intractable perianal disease.

Comparison of sodium and potassium intake with excretion.

Nine well-motivated adults, knowledgeable about nutrition, kept food records, saved food portions equal to what had been eaten, and collected 24-hour urine samples for 3 consecutive days. Estimates of sodium and potassium intake were calculated from food table analyses of written food records and from flame photometric analyses of food portions. For each subject the mean of the estimates for each of the 3 days was compared with the mean of urine analyses for sodium and potassium for each of the 3 days. For the group of nine subjects, the average estimate of sodium intake from analyses of food records was 11% lower than the average estimate of urinary sodium excretion; the average estimate of sodium intake from analysis of food portions was 2% higher than urinary sodium excretion. For individuals, there were large differences between estimates of intake and measurement of sodium excretion. For the group of nine subjects, the average estimate of potassium intake from analysis of food records was less than 1% lower than the average estimate of potassium urinary excretion; the average estimate of potassium intake from analysis of food portions was 13% higher than potassium urinary excretion. For individuals, as with sodium, there were large differences between estimates of intake and measurement of potassium excretion.

Nutrient intakes of children on the hyperkinesis diet.

The nutrient intakes of fifty-four hyperactive children during a baseline period and while following the hyperkinesis diet were calculated. During both periods, mean dietary intakes compared favorably with the Recommended Dietary Allowances. A comparison of three-day food records showed that, relative to baseline values, nutrient intakes did not change significantly while the children followed the hyperkinesis diet. The majority of the children reported intakes sufficient to meet the recommended allowances during both the baseline and diet periods.