The value of ileoscopy with biopsy in the diagnosis of intestinal Crohn's disease

Studies to determine the diagnostic value of ileoscopy and biopsy are not available. In an attempt to clarify the role of this technique in the diagnosis of intestinal Crohn's disease, 110 patients with a radiological diagnosis of inflammatory disease of the terminal ileum were examined in a prospective study. Suspicion of Crohn's disease was rejected in 28 patients. In 18 patients the terminal ileum was normal, while 10 patients had lymphoid nodular hyperplasia. Endoscopic lesions with a predictive value of 0.96 were found in 25 of 48 patients with the final diagnosis of Crohn's disease. Diagnostic granulomas were only found in 4 patients, but lesions consistent with Crohn's disease were present in the pathology sections of 17 patients. It was concluded that ileoscopy with biopsy is a valuable tool in the diagnosis of inflammatory ileal disease and can provide useful information about the nature and extent of the inflammation.

Natural history of recurrent Crohn's disease at the ileocolonic anastomosis after curative surgery

An endoscopical and histological study was carried out in 114 patients, treated by 'curative' resection of the terminal ileum and part of the colon for Crohn's disease, in order to study the natural history of recurrent Crohn's disease. The recurrence rate of Crohn's disease in patients examined within one year of the operation was 72%. This figure did not differ significantly from that in patients examined one to three years or three to 10 years after surgery (79% and 77% respectively). Recurrence was located in the neoterminal ileum and at the anastomosis in 88% of the patients. Early endoscopic signs of recurrence were small aphthous ulcers in the neoterminal ileum. Ileal biopsies at this stage showed an important inflammatory cell infiltrate of the lamina propria with numerous eosinophils and fusion and blunting of the villi. More advanced lesions observed in patients examined one to three years after surgery, consisted of larger, often serpiginous ulcerations and nodular thickening of folds. In patients examined three to 10 years after the operation, the anastomosis was frequently stenosed and rigid, with large ulcers extending from the stenosis into the colon. Mucosal granulomas may be found in normal appearing mucosa as well as in the obviously inflamed mucosa surrounding the ulcers. These studies suggest that recurrence of Crohn's disease almost always develops in the first year after the operation. Significant endoscopic lesions may be present without clinical symptoms, particularly in the earlier stages of the disease.

A new and effective technique of Yag laser photocoagulation for severe upper gastrointestinal bleeding

A new technique of treating acute severe upper gastrointestinal haemorrhage was evaluated. The technique consisted of epinephrine injections in the bleeding lesion combined with YAG laser radiation in short pulses, applied until the bleeding vessel was completely closed. This new treatment modality was tried in 54 consecutive patients with severe upper gastrointestinal bleeding from a spurting artery, or an ulcer with a non-bleeding visible vessel in the floor of the ulcer crater at endoscopy. Permanent haemostasis was achieved in 87% of the 54 patients. Emergency surgery was needed in 13%. The mortality rate was only 10%. No complications occurred. It is concluded that this new technique of treating severe upper gastrointestinal bleeding from a spurting artery, or an ulcer with a visible vessel results in a significant improvement of the success rate (permanent haemostasis) and a marked reduction in the mortality rate.

Does intercurrent hepatitis have a beneficial effect on the course of Crohn's disease?

Four patients who developed acute viral hepatitis in the course of active Crohn's disease are reported upon. Three of these patients (1 with hepatitis A and 2 with hepatitis B) had a very striking and unusual clinical remission or apparent healing on regression of the hepatitis. These observations suggest that intercurrent hepatitis may have a beneficial effect on the course of active Crohn's disease.

Acute infective colitis caused by endemic pathogens in western Europe: endoscopic features

In a 4-year period 45 patients were admitted to our gastroenterological u nit with acute infective colitis. The endemic pathogens responsible for the colitis were Yersinia enterocolitica (46%), Campylobacter fetus jejuni (20%), common Salmonellae (13%), less virulent strains of Shigella (9%), Entamoeba hystolytica (7%) and Cytomegalovirus (4%). These microorganisms caused very severe disease in 18% of the patients, who were mostly predisposed. While Salmonella- and amoebic colitis always mimicked ulcerative colitis by the presence of diffuse lesions, the other pathogens caused focal colitis, thus necessitating differential diagnosis vis a vis Crohn's colitis. Two patients (4%) died of complications, while 93% of the patients were cured by proper antimicrobial therapy. In the same period 12 patients were admitted with an acute attack of inflammatory bowel disease due to an intercurrent infection with the same pathogens. In most of these patients clinical remission of IBD was achieved by treating the intercurrent infection. These data indicate that in the presence of an acute attack of colitis an infective etiologic agent must always be sought, and that an attack of chronic idiopathic inflammatory bowel disease may be caused by an intercurrent infection.

Achalasia, diffuse esophageal spasm, and related motility disorders

From 1972 to 1977, the authors observed 156 patients with primary esophageal motility disorders which caused such a severe degree of dysphagia that treatment by pneumatic dilatation was deemed necessary. Before dilatation, 24% of the patients presented with motility disorders that did not fit well into the two classical disease entities, diffuse esophageal spasm and achalasia (absence of peristalsis with presence of lower esophageal sphincter (LES) relaxations or presence of peristalsis with absence of LES relaxations). After treatment with pneumatic dilatation, these "intermediate" forms constituted 45% of the motor disorders. This was due mainly to the reappearance, on manometric tracings, of peristaltic contractions and of LES relaxations. Radiologic and manometric observations suggest that in many patients, this "return of peristalsis" may be an apparent change in pressure pattern rather than a real change in motility. In 6 of the 156 patients, a deterioration of the esophageal motility disorder was observed, which was characterized by the loss of peristalsis and of LES relaxations over a period of a few months or years. The frequent occurrence of intermediate types of motility disorders and the transition from diffuse spasm to achalasia suggest that achalasia and diffuse esophageal spasm are part of a spectrum of related motor disorders.