Inflammatory bowel disease (1)

Crohn9s disease is a chronic granulomatous ileocolitis, of unknown etiology, which generally affects the patient during the prime of life. Medical treatment is supportive at best, and patients afflicted with this disorder generally live with chronic pain, in and out of hospitals, throughout their lives. The disease bears the name of the investigator who convincingly distinguished this disease from intestinal tuberculosis in 1932. This distinction was not universally accepted, and the notion of a mycobacterial etiology has never been fully dismissed. Nevertheless, it was 46 years after the distinction of Crohn9s disease and intestinal tuberculosis before research attempting to reassociate mycobacteria and Crohn9s disease was published. Recently, there has been a surge of interest in the possible association of mycobacteria and Crohn9s disease due largely to the isolation of genetically identical pathogenic Mycobacterium paratuberculosis from several patients with Crohn9s disease in the United States, the Netherlands, Australia, and France. These pathogenic organisms have been isolated from only a few patients, and direct evidence for their involvement in the disease process is not clear; however, M. paratuberculosis is an obligate intracellular organism and strict pathogen, which strongly suggests some etiologic role. Immunologic evidence of a mycobacterial etiology, as assessed by humoral immune determinations, has been conflicting, but evaluation of the more relevant cellular immunity has not been performed. Data from histochemical searches for mycobacteria in Crohn9s disease tissues have been equally conflicting, with acid-fast bacilli detected in 0 to 35% of patients. Animal model studies have demonstrated the pathogenic potential of isolates as well as elucidated the complexity of mycobacterial-intestinal interactions. Treatment of Crohn9s disease patients with antimycobacterial agent has not been fully assessed, although case reports suggest efficacy. The similarities in the pathology, epidemiology, and chemotherapy of Crohn9s disease and the mycobacterioses are discussed. The issue is fraught with controversy, and the data generated on the association of mycobacteria and Crohn9s disease are in their infantile stages so that a general conclusion on the legitimacy of this association cannot be made. While no firm evidence clearly implicates mycobacteria as an etiologic agent of Crohn9s disease, the notion is supported by suggestive and circumstantial evidence and a remarkable similarity of Crohn9s disease to known mycobacterial diseases.

Crohn's disease and the mycobacterioses: a review and comparison of two disease entities.

THE "nonspecific" inflammatory bowel diseases include ulcerative colitis and proctitis and Crohn's disease of the gastrointestinal tract. Their causes and precise relations remain obscure, and thei...

Recent developments in nonspecific inflammatory bowel disease (second of two parts).

https://www.gastrojournal.org/article/0016-5085(84)90119-7/pdf

A diagnostic score for the irritable bowel syndrome: Its value in the exclusion of organic disease

SUMMARY The solitary ulcer syndrome of the rectum is not rare but often remains unrecognised. A greater awareness of the condition will lead to more frequent diagnosis. The aetiology remains unproven but the evidence would suggest that a combination of prolapse, trauma and ischaemia, caused by excessive straining at stool may be important factors. The reasons for straining at stool are also obscure but in some cases a failure in the normal behaviour of the puborectalis may be involved. The history and clinical features of the condition are described, and the pathogenesis discussed.

The solitary ulcer syndrome of the rectum.

Extraintestinal complications of inflammatory bowel disease are well recognized, but extraintestinal primary Crohn's lesions are less common. Unusual bone1, synovial2 and vulvar3 granulomatous involvement has recently been described. Granulomatous myositis and myopathy may also accompany Crohn's colitis. Case Report A 44-year-old man was admitted to the hospital with a six-week history of non-bloody diarrhea, crampy abdominal pain, arthralgia, fever and a 4.5-kg weight loss. Physical examination was unremarkable. Proctoscopy was normal to a level of 20 cm from the anal margin, at which point multiple ulcerations, 2 to 3 mm, extended to the length of the proctoscope. Biopsies showed . . .

Granulomatous myositis and myopathy associated with crohn's colitis.

Three patients with Crohn’s disease primarily involving the large intestine had unusual abscesses of the vulvar area. At biopsy, the abscesses had classic features of the primary disease and were clearly separated from the intestinal tract. There was no fistula in the anal canal, and the perineum between the vulvar abscess and the anus was normal. One of the patients also had an early lesion of Crohn’s disease in the sigmoid. The lesion appeared as a small erythematous spot without ulceration. Biopsy revealed a typical granuloma under an intact mucosa. It is concluded that Crohn’s disease is not confined to the gastrointestinal tract, and that early lesions of the disease within the gastrointestinal tract are submucosal rather than mucosal.

Crohn's disease of the vulva.

In 35 patients with punched out ulcerations of the rectum and/or sigmoid, 12 different etiologies were found to be responsible for the lesions. Regional enteritis and traumatic ulcerations were the most frequently made diagnoses. One patient suffered from ulcerations of a chronic progressive nature which healed after vascular reconstruction of the inferior mesenteric artery. Evaluation of the pathologic material accumulated on patients with regional enteritis demonstrated the value to the pathologist of more than one biopsy. Thus, extensive investigations should be done in all patients with discrete ulcerations of the rectum and sigmoid, and a diagnosis of regional enteritis should not be excluded on the basis of pathology alone, especially when only a single biopsy has been obtained.

Discrete ulcerations of the rectum and sigmoid.

Large Bowel Motility Disorders

Of 213 patients with proctitis of all etiologies seen between 1977 and 1987, we studied an original cohort of 96 patients with idiopathic ulcerative proctitis (mean follow-up of 62 months). The diagnosis was made according to strict inclusion criteria, and all cases with any initial feature suggestive of Crohn's disease were excluded. Follow-up showed that 13 patients (13.6%) eventually progressed to Crohn's disease, usually within the first 3 years of the initial diagnosis of idiopathic ulcerative proctitis. Their clinical, endoscopic and histological features at initial presentation were indistinguishable from those in whom the diagnosis remained that of idiopathic ulcerative proctitis. In nine of 13 of these patients (70.0%), the clinical course was characterized by a more protracted course and a poorer response to standard treatment. Such features were not found in those in whom the diagnosis of idiopathic ulcerative proctitis was maintained. Clinicians should be aware that Crohn's disease may present initially as apparent idiopathic ulcerative proctitis.

Henry Haddad

Papers

Granulomatous myositis and myopathy associated with crohn's colitis.

Crohn's disease of the vulva.

Discrete ulcerations of the rectum and sigmoid.

Large Bowel Motility Disorders

Idiopathic ulcerative proctitis may be the initial manifestation of Crohn's disease.