CROHN'S DISEASE

7. AUTHORdel-Gaudio-A, Bragaglia-R-B, Boschi-L, del-Gaudio-G-A, Accorsi-D.
INSTITUTIONDepartment of Surgery, University of Bologna, School of Medicine, Italy.
TITLEA new approach in the management of Crohn's disease: observations in 20 consecutive cases.
SOURCEHepatogastroenterology 1997 Jul-Aug, VOL: 44 (16), P: 1095-103, ISSN: 0172-6390.
ABSTRACTAlthough the "modern history" of Crohn's disease dates back to 1932, the etiology is still nebulous, the medical treatment inefficient and resective surgery results in a high recurrence rate. Twenty consecutive patients with terminal ileitis underwent ileo-cecal resection and mesenteric-epiploonplasty to enhance collaterals and lymphatic drainage. This approach was advised by experimental observations (the ligation of colonic lymphatic ducts in rabbits), by the intraoperative use of optics to better appreciate the details of the diseased bowel before and after injecting dye and by the angiographic results in one patient. In rabbit experiments, the obliteration of lymphatic drainage led to Crohn's disease-like macroscopic and microscopic patterns, while diffusion of the dye injected in the diseased segment showed altered lymph flow. The angiographic study in one patient confirmed the presence of vascular anomalies. Direct observation through optics revealed large vessels in the serosa with milky contents and the oozing of sticky exudate. In the 8 patients who underwent this procedure over 5 years ago, there were no recurrences. We strongly believe in the vasculo- lymphatic etiology of Crohn's disease and in mesentery-epiploonplasty as the only actual indirect approach to resolve hemolymphatic obstructions. Author.
  
8. AUTHORLopez-Cubero-S-O, Sullivan-K-M, McDonald-G-B.
INSTITUTIONClinical Research Division, Fred Hutchinson Cancer Research Center, and University of Washington School of Medicine, Seattle 98109-1024, USA.
TITLECourse of Crohn's disease after allogeneic marrow transplantation (see comments).
SOURCEGastroenterology 1998 Mar, VOL: 114 (3), P: 433-40, ISSN: 0016-5085. CM Comment in: Gastroenterology 1998 Mar; 114(3):596-8.
  
ABSTRACTBACKGROUND & AIMS: Remission of several autoimmune diseases has been described after allogeneic marrow transplantation. The aim of this study was to determine if the natural history of Crohn's disease was altered by hematopoietic cell transplants from healthy allogeneic donors. METHODS: Between 1982 and 1992, 6 patients with Crohn's disease and leukemia underwent allogeneic marrow transplantation and were followed up clinically. RESULTS: Five patients had active Crohn's disease before transplantation, and 3 had clinical evidence of sclerosing cholangitis. Four marrow donors were HLA-identical siblings, 1 related donor was mismatched at the DR locus, and 1 unrelated donor was HLA-matched. One patient died of septicemia 97 days after transplantation; 5 patients were observed for 4.5, 5.8, 8.4, 9.9, and 15.3 years after transplantation. Four of 5 patients evaluated had no signs or symptoms of Crohn's disease after transplantation. One patient with mixed donor-host hematopoietic chimerism had a relapse of Crohn's disease 1.5 years after transplantation. CONCLUSIONS: Four of 5 patients followed up for 4.5 to 15.3 years after allogeneic hematopoietic cell transplantation remained free of Crohn's disease. These observations suggest that host immune dysregulation plays a role in the perpetuation of Crohn's disease that can be corrected by allogeneic hematopoietic cell transplantation. Author.
  
9. AUTHORLoftus-E-V-Jr, Silverstein-M-D, Sandborn-W-J, Tremaine-W-J, Harmsen- W-S, Zinsmeister-A-R.
INSTITUTIONInflammatory Bowel Disease Clinic, Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA. loftus.edward@mayo.
TITLECrohn's disease in Olmsted County, Minnesota, 1940-1993: incidence, prevalence, and survival.
SOURCEGastroenterology 1998 Jun, VOL: 114 (6), P: 1161-8, ISSN: 0016-5085.
ABSTRACTBACKGROUND & AIMS: Many centers worldwide have reported an increased incidence of Crohn's disease, but population-based data in North America are sparse. We studied the incidence and prevalence of Crohn's disease in Olmsted County, Minnesota, and examined temporal trends in incidence and survival. METHODS: Residents diagnosed with Crohn's disease between 1970 and 1993 were incidence cases, and residents with Crohn's disease who were alive on January 1, 1991, were prevalence cases. Cases from previous studies were reconfirmed. Rates were adjusted using 1990 U.S. Census figures for whites. Incidence trends were evaluated with a Poisson regression model. Survival from diagnosis was compared with that expected for U.S. north-central whites. RESULTS: Between 1940 and 1993, 225 incidence cases were identified, for an adjusted incidence rate of 5.8 per 100,000 person-years. On January 1, 1991, there were 145 residents with Crohn's disease, an adjusted prevalence rate of 133 per 100,000, 46% higher than that seen in 1980. Incidence rates before 1964 were significantly lower than those of 1989-1993. Observed survival was less than expected (P = 0.007). CONCLUSIONS: The incidence of Crohn's disease has stabilized since the 1970s at a rate higher than that seen previously. Prevalence has increased by 46% since 1980. Overall survival is slightly decreased. Author.
  
10. AUTHORFonager-K, Sorensen-H-T, Olsen-J.
INSTITUTIONDanish Epidemiology Science Centre, University of Aarhus, Denmark.
TITLEChange in incidence of Crohn's disease and ulcerative colitis in Denmark. A study based on the National Registry of Patients, 1981-1992.
SOURCEInt-J-Epidemiol 1997 Oct, VOL: 26 (5), P: 1003-8, ISSN: 0300-5771.
ABSTRACTBACKGROUND: The incidence of inflammatory bowel disease (IBD) in Denmark is considered to be among the highest in Europe. However, the diseases are relatively rare and therefore it would be useful if existing registers could replace ad hoc examination in the surveillance of IBD. METHODS: The present study used the Danish National Registry of Patients to estimate incidence rates, 1981-1992. RESULTS: A total of 2806 patients with Crohn's disease (CD) and 8125 with ulcerative colitis (UC) were identified. The mean incidence for CD was 4.6 (5.4 for women and 3.7 for men) per 100,000 per year, with a peak incidence in younger women. The incidence increased in most age groups with the highest increase in older women. The mean incidence for UC was 13.2 (13.4 for women and 13.0 for men) per 100,000 per year, with the highest incidence in older men. A decreasing tendency in the incidence was present in most age groups. CONCLUSIONS: The present study found an increasing incidence for CD and a stable incidence with a tendency to decrease for UC. Comparison with ad hoc studies indicates that it is possible to use the Danish National Registry of Patients in the surveillance of IBD, especially for CD. Author.
  
11. AUTHORLapidus-A, Bernell-O, Hellers-G, Persson-P-G, Lofberg-R.
INSTITUTIONDepartment of Gastroenterology, Karolinska Institute,, Huddinge University Hospital, Sweden.
TITLEIncidence of Crohn's disease in Stockholm County 1955-1989.
SOURCEGut 1997 Oct, VOL: 41 (4), P: 480-6, ISSN: 0017-5749.
ABSTRACTAIM: To evaluate the incidence of Crohn's disease in Stockholm County between 1955 and 1989. METHODS: A cohort of 1936 patients with Crohn's disease was retrospectively assembled. Incidence rates and changes in disease distribution were assessed. RESULTS: The mean increase in incidence was 15% (95% confidence intervals 12% to 18%) per five year period with a mean annual incidence rate at 4.6/10(5) during the last two decades. The mean incidence for the entire study period was similar for men and women. The mean age at diagnosis increased from 25 years in 1960-64 to 32 years in 1985-89, partly because of an increasing proportion of patients aged at least 60 years at diagnosis. The proportion of patients with colonic Crohn's disease at the time of diagnosis increased from 15% to 32% (17% difference; 95% confidence intervals 12% to 23%) whereas the proportion of patients with ileocaecal disease decreased from 58% to 41% (17% difference; 95% confidence intervals 10% to 24%) during the study period. Elderly patients had a higher proportion of small bowel disease and a lower proportion of ileocolonic disease compared with the younger patients. CONCLUSION: The incidence rate of Crohn's disease in Stockholm has stabilised at 4.6/10(5) and the proportion of elderly patients has increased during a 35 year period. Colonic Crohn's disease has increased in frequency with a reciprocal decrease in ileocaecal disease. Author.
  
12. AUTHORWolff-B-G.
INSTITUTIONDepartment of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota 55905, USA.
TITLEFactors determining recurrence following surgery for Crohn's disease.
SOURCEWorld-J-Surg 1998 Apr, VOL: 22 (4), P: 364-9, ISSN: 0364-2313 57 Refs.
ABSTRACTMany factors have been examined in an attempt to define groups at higher risk for recurrence or recrudescence of Crohn's disease. Among these factors are age and onset of disease, gender, site of disease, number of resections, symptomatic status at the time of surgery, length of small bowel resection, fistulizing versus obstructive forms of disease, proximal margin length, microscopic margin histology, strictureplasty, and number of sites of disease, as well as the presence of colonic only disease, the presence of granulomas, blood transfusions, family history, and prophylactic treatment. To date, only proctocolectomy with Brooke ileostomy versus other procedures for colonic only disease, and prophylactic treatment have been shown with some degree of confidence to lead to a lower recurrence rate after surgery for Crohn's disease. Author.
  
13. AUTHORElton-E, Hanauer-S-B.
INSTITUTIONSection of Gastroenterology, Department of Medicine, University of Chicago, IL 60637, USA.
TITLEReview article: the medical management of Crohn's disease.
SOURCEAliment-Pharmacol-Ther 1996 Feb, VOL: 10 (1), P: 1-22, ISSN: 0269-2813 264 Refs.
  
ABSTRACTThe choice of medical therapies for Crohn's disease continues to grow. Although our understanding of the mechanisms of the disease is incomplete, increasing knowledge of the pathogenesis of inflammation in general and Crohn's disease in particular allows targeting of therapies at various points in the immunoinflammatory cascade. In addition, the division of Crohn's disease into subtypes by location, aggressiveness, and the presence or absence of perianal and fistulizing disease allows the tailoring of medical therapy to the individual patient. For those patients with moderate to severe symptoms or frequent flares of disease activity, and those who have required surgical resection, maintenance therapy can substantially reduce the rate of recurrence. Despite these advances, available medical therapies for Crohn's disease remain imperfect, as evidenced by their sometimes substantial toxicities and the continued frequent need for surgery. Author.
  
14. AUTHORBorkje-B, Gronbech-J-E.
INSTITUTIONMedisinsk avdeling, Haukeland sykehus, Bergen.
TITLE(Crohn disease. Diagnosis and treatment). TT Crohns sykdom. Diagnostikk og behandling.
SOURCETidsskr-Nor-Laegeforen 1991 Feb 20, VOL: 111 (5), P: 593-7, ISSN: 0029-2001 67 Refs.
ABSTRACTCrohn's disease was the topic of a meeting of gastroenterologists in Bergen last year with the purpose of working out consensus guidelines for diagnosis and treatment of this chronic disease. The most important diagnostic procedures are radiology, gastrointestinal endoscopy and histopathology. Transmural, segmental involvement is characteristic, whereas granulomas are found in only 25% of biopsy specimens. Corticosteroids are effective in active Crohn's disease located to all parts of the intestine, whereas sulfasalazine and metronidazole are most effective in Crohn's colitis. Azathioprine and 6-mercaptopurine should be reserved for patients with chronic active disease that is unresponsive to steroids or requires higher doses. Azathioprine also has a prophylactic effect. Surgery is indicated in patients whose quality of life is diminished in spite of adequate medical treatment, in patients with bowel or ureter stenosis, fistula or abscess, and in patients with acute perforation or toxic dilatation. Limited resection is recommended, and stricture plasty can be alternative to extensive resection. Author.
  
15. AUTHORvan-Deventer-S-J, Elson-C-O, Fedorak-R-N.
INSTITUTIONAcademic Medical Center, Amsterdam, The Netherlands.
TITLEMultiple doses of intravenous interleukin 10 in steroid-refractory Crohn's disease. Crohn's Disease Study Group.
SOURCEGastroenterology 1997 Aug, VOL: 113 (2), P: 383-9, ISSN: 0016-5085.
ABSTRACTBACKGROUND & AIMS: Interleukin 10 (IL-10) is a cytokine with immunosuppressive and anti-inflammatory activities. Gene-targeted IL-10-deficient mice develop a chronic intestinal inflammatory disease that is reminiscent of Crohn's disease. The present double- blind randomized multicenter trial was designed to evaluate the safety, tolerance, and pharmacokinetics of IL-10 in Crohn's disease. METHODS: Forty-six patients with active steroid-resistant Crohn's disease were treated with one of five doses of recombinant human IL-10 (0.5, 1, 5, 10, or 25 micrograms/kg) or placebo administered once daily by intravenous bolus injection over 7 consecutive days. RESULTS: Treatment was safe and well tolerated, and no evidence for IL-10 accumulation was observed at the end of the treatment period. At the end of the study, Crohn's disease activity scores were 179 in IL-10-treated patients and 226 in patients receiving placebo. The proportion of patients that experienced a complete remission at any time in the 3-week follow-up period was 50% in the IL-10 group and 23% in placebo-treated patients. CONCLUSIONS: These results indicate that IL-10 administered as a daily bolus injection over 1 week is safe and well tolerated and may be clinically efficacious. Author.
  
16. AUTHORYazdanpanah-Y, Klein-O, Gambiez-L, Baron-P, Desreumaux-P, Marquis-P, Cortot-A, Quandalle-P, Colombel-J-F.
INSTITUTIONClinique des Maladies de l'Appareil Digestif et de la Nutrition, Hopital Huriez, CH et U Lille, France.
TITLEImpact of surgery on quality of life in Crohn's disease.
SOURCEAm-J-Gastroenterol 1997 Oct, VOL: 92 (10), P: 1897-900, ISSN: 0002-9270.
ABSTRACTOBJECTIVE: Health-related quality of life (HRQOL) status is an important component in assessing the impact of disease and its treatments in patients with chronic disorders. We recently validated a HRQOL questionnaire in French patients with inflammatory bowel disease. The aim of this study was to evaluate prospectively the impact of surgery on HRQOL in patients operated on for Crohn's disease (CD). METHODS: Twenty-six patients (14 women, 12 men; median age 28.5 yr) undergoing an elective ileocolonic resection for CD were studied. The HRQOL questionnaire comprised a general questionnaire of 36 items (Medical Outcomes Study-Short Form 36), to which was added a sleep module, and a specific questionnaire of 28 items (Rating Form of Inflammatory Bowel Disease Patient Concerns), to which were added three independent items because of their pertinence in the French population. HRQOL was assessed immediately preoperatively and 3 months postoperatively. RESULTS: HRQOL was improved postoperatively compared with the immediate preoperative status in almost all scales. Patient concerns and worries decreased after surgery. However, ranking was unchanged for the five most intense concerns: having an ostomy bag, having surgery, energy level, uncertainty of the disease, and pain or suffering. CONCLUSIONS: HRQOL is greatly improved after surgery for CD, and this reassuring message might be delivered to our patients. In addition, the questionnaire showed the ability to detect clinical changes over time. This attests to its potential use in research. Author.
  
17. AUTHORNissan-A, Zamir-O, Spira-R-M, Seror-D, Alweiss-T, Beglaibter-N, Eliakim-R, Rachmilewitz-D, Freund-H-R.
INSTITUTIONDepartment of Surgery, Hadassah University Hospital, Mount Scopus, and the Hebrew University Hadassah Medical School, Jerusalem, Israel.
TITLEA more liberal approach to the surgical treatment of Crohn's disease.
SOURCEAm-J-Surg 1997 Sep, VOL: 174 (3), P: 339-41, ISSN: 0002-9610.
  
ABSTRACTBACKGROUND: Surgery for Crohn's disease is not intended for cure, but rather to relieve symptoms and treat complications. Perioperative morbidity, the fear of creating short bowel syndrome, and the tendency of the disease to recur convinced many physicians to refer their Crohn's patients for surgery only when life-threatening complications occur. METHODS: This is a retrospective analysis of 47 patients operated on for Crohn's disease between 1989 and 1994. Twenty-six patients were operated on for "classic" indications ("classic" group) and the other 21 were operated on to improve their quality of life ("quality" group). RESULTS: There was no operative or postoperative mortality during a mean follow-up period of 50 (27 to 84) months. All major postoperative complications occurred only in patients operated on for the classic indications (four abscesses, two fistulas, one wound dehiscence, and two small bowel obstructions). During the follow-up period, a total of 13 patients (50%) in the classic group and only 5 patients (24%) in the quality group required reintroduction of medical therapy or additional operations for exacerbations and complications of Crohn's disease. CONCLUSIONS: Our data suggest that surgical intervention intended to improve the quality of life for Crohn's disease patients is safe and effective for carefully selected patients. It does improve quality of life, may prevent life-threatening complications, and offers a lower recurrence rate following surgery. Author.
  
18. AUTHORHeimann-T-M, Greenstein-A-J, Lewis-B, Kaufman-D, Heimann-D-M, Aufses- A-H-Jr.
INSTITUTIONDepartment of Surgery, The Mount Sinai School of Medicine, New York, New York, USA.
TITLEComparison of primary and reoperative surgery in patients with Crohns disease.
SOURCEAnn-Surg 1998 Apr, VOL: 227 (4), P: 492-5, ISSN: 0003-4932.
ABSTRACTOBJECTIVE: This study was performed to determine the clinical results of patients with Crohns disease who require surgical resection. The outcome of patients undergoing initial surgery was compared with those having reoperation. METHODS: One hundred sixty-four patients undergoing intestinal resection for Crohns disease at The Mount Sinai Hospital from 1976 to 1989 were studied prospectively. The mean duration of follow-up was 72 months. RESULTS: Ninety patients (55%) underwent initial intestinal resection whereas 74 patients (45%) underwent reoperation for recurrent disease. Patients undergoing reoperation were older (33.4 vs. 38.7 years), had longer durations of disease (8.7 vs. 15.2 years), had shorter resections (60 vs. 46 cm), and were more likely to require ileostomy. Forty-seven percent of the patients with multiple previous resections required an ileostomy. This group also received a mean of 2.3 U blood in the perioperative period and showed a trend to increased symptomatic recurrence (49% vs. 71% at 5 years). CONCLUSIONS: Patients with Crohns disease undergoing first and second reoperation have outcomes similar to those in patients undergoing primary resection. Patients requiring multiple reoperations are more likely to require blood transfusions and permanent ileostomy and to show a greater trend to early symptomatic recurrence. Author.
  
19. AUTHORFurst-H, Schildberg-F-W.
INSTITUTIONChirurgische Klinik und Poliklinik, Ludwig Maximilians Universitat Munchen, Klinikum Grosshadern, Munchen.
TITLE(Surgical treatment of inflammatory bowel diseases). TT Chirurgische Behandlung entzundlicher Darmerkrankungen.
SOURCERadiologe 1998 Jan, VOL: 38 (1), P: 8-14, ISSN: 0033-832X 32 Refs.
ABSTRACTPURPOSE: To summarize current knowledge on surgical therapy in patients with inflammatory bowel disease (Crohn's disease, ulcerative colitis and diverticulitis). MATERIAL AND METHODS: To discuss surgical indications and strategies, we reviewed major peer review publications of the last 10 years, and we also analysed data from patients with Crohn's disease who were treated in our institution between 1978 and 1994. RESULTS: With Crohn's disease (305 patients), emergency surgery should be avoided as much as possible, since morbidity (50% vs 8.8%) and mortality (11% vs 0.6%) rise significantly in comparison to elective procedures. With ulcerative colitis, operative therapy is indicated in patients with secondary malignoma, and urgent surgery is requested in cases with associated perforation, toxic megacolon or massive bleeding. With diverticulitis, the first episode should be managed conservatively. Surgery is indicated in patients with recurrent episodes or with secondary complications. DISCUSSION: For treating patients with Crohn's disease or with diverticulitis, an indication for surgery should not be delayed and should be made before complications develop to avoid high risk emergency surgery. Elective surgery in patients with ulcerative colitis usually consists in proctocolectomy. Individual findings and aspects will determine the decision whether to construct an ileoanal pouch or whether ileostoma is more appropriate. Author.
  
20. AUTHORTravis-S-P.
INSTITUTIONGastroenterology Unit, Derriford Hospital, Plymouth, UK.
TITLEReview article: insurance risks for patients with ulcerative colitis or Crohn's disease.
  
SOURCEAliment-Pharmacol-Ther 1997 Feb, VOL: 11 (1), P: 51-9, ISSN: 0269-2813 23 Refs. ABSTRACT
ABSTRACTProspective population-based studies have allowed a re-evaluation of the risks of insuring patients with ulcerative colitis or Crohn's disease. Life expectancy, the risk of cancer and working capacity are very much better than previously recognised and are normal for many patients. Three population-based studies in ulcerative colitis have shown a mortality similar to or slightly less than the general population except in the first year after diagnosis, whilst two have shown a slightly higher mortality (standardized mortality ratio, SMR = 1.4), except for those with proctitis. In Crohn's disease, two population-based studies have also shown an increased mortality (SMR = 1.4), which is similar to that of unskilled manual labourers (SMR = 1.43) from all causes of death. Three other studies have shown no increase in overall mortality, except in the first 5 years after diagnosis, in those with proximal small intestinal disease and in some patients needing multiple operations. Insurance risks should be evaluated on an individual basis, after details of the extent and pattern of disease have been obtained. Although the 'standard life' in insurance terms differs from that of the general population, because people who seek life assurance are self-selected from a more affluent section of society, many patients can be identified who have a particularly good prognosis. These include patients with ulcerative proctitis, those with left-sided colitis in extended remission (> 12 months), and patients more than 30 years old with localized ileal or ileocaecal Crohn's disease that has responded to treatment. From the published data, it is difficult to justify increasing the insurance premium in such patients. Author.
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