Gut, 1971, 12, 11-15 The effects of diversion of intestinl contents on the progress of Crohn's disese of the lrge owel J. H. BURMAN, H. THOMPSON, W. T. COOKE, AND J. ALEXANDER WILLIAMS From the Nutritionl nd Intestinl Unit, The Generl Hospitl, Birminghm SUMMARY This study shows tht fecl diversion y ileostomy or colostomy results in n improvement in the ptient's generl helth which is sustntited y the hemtologicl nd iochemicl findings. However, in the owel distl to the diversion there is lwys histologicl evidence of mucosl nd trnsmurl disese nd complictions such s fistule my still occur. In only two ptients (7 %) ws restortion of owel continuity successful. Preliminry reports hve suggested tht in Crohn's disese of the colon diversion of intestinl contents y defunctioning ileostomy or colostomy would so 'rest' the distl disesed owel tht restortion of the fecl strem might e fesile lter (Truelove, Ellis, nd Wester, 1965; Oerhelmn, Kohtsu, Tylor, nd Kivel, 1968). Successful restortion of intestinl continuity ws reported recently in three out of 18 (16.6%,) ptients (Oerhelmn, Koht, Tylor, nd Porteous, 1970). This pper presents study of 29 ptients with Crohn's disese in whom defunctioning ileostomy or colostomy hs een performed. These ptients hve een reviewed in n ttempt to evlute: (1) the clinicl improvement fter diversion, (2) the degree of resolution of disese ctivity in the ypssed owel, nd (3) the fesiility nd success of restortion of continuity. Ptients There were 15 men nd 14 women in this study which extended from 1947 to 1969 with men follow up of 10 yers. All hd Crohn's disese of the lrge owel dignosed y rium studies, together with histologicl evidence. There ws evidence of previous smll owel disese in eight ptients nd concurrent smll owel disese ws oserved t opertion in seven. In ddition, smll owel disese developed susequently in six ptients etween eight months nd six yers fter colectomy. Three ptients in this series re ded: Received for puliction 29 Septemer 1970. one from cute hemorrhgic ileitis five yers fter pn-proctocolectomy, the second from multiple entero-enteric fistule one yer fter colectomy, nd the third from smll owel infrction seven yers fter closure of the colostomy. Methods Indices of generl helth efore nd fter diversion were tken from historicl records. Detils of weight nd hemogloin levels (24 ptients) were collected, together with vlues of serum lumin (21 ptients) nd serum seromucoid (15 ptients). An ssessment of disese ctivity in the defunctioned owel ws sought from the susequent course of events in ech cse either from sigmoidoscopy nd iopsy or from histologicl exmintion fter lter excision. At sigmoidoscopy mucosl ulcertion nd friility with contct leeding were tken to e criteri of continued ctivity of the disese. Histologiclly evidence of continued ctivity ws inferred from the presence of n inflmmtory cellulr infiltrte, mucosl ulcertion, sumucosl oedem nd firosis, or the presence of gint cells. Finlly, the presence nd progress of perinl disese ws oserved. Results THE EFFECT OF DIVERSION ON THE GENERAL HEALTH OF THE PATIENT Following diversion, ll ut one ptient showed improvement in generl helth. This ptient ecme 11 Gut: first pulished s 10.1136/gut.12.1.11 on 1 Jnury 1971. Downloded from http://gut.mj.com/ on 7 My 2018 y guest. Protected y copyright.
12 cutely depressed. Of the 18 ptients with ccurte weight records, 15 gined weight, two lost weight, nd one remined the sme. In those ptients where records were ville, hemogloin vlues rose in every cse ut one (Fig. 1) nd serum lumin levels rose in ll ut three cses (Fig. 2). An nticipted fll in serum seromucoid levels took plce in every cse ut one; in only six ptients, however, did the vlues fll to the norml level (Fig. 3). Figures 1, 2, nd 3 show the verge of the vlues found up to two months efore diversion nd up to 12 months fter diversion in ech ptient. The Figures show ptients sudivided into those in whom some owel resection ws undertken t the time of diversion nd those in whom only diversion ws performed. Although the improvement oserved ws usully greter if some disesed owel ws lso resected, there is no significnt difference etween the two sugroups. PERIANAL DISEASE Perinl disese ws oserved in 10 ptients efore diversion. Two ptients hd fissure in no, seven hd fistul in no, nd one mn hd oth. diversion, over men follow-up period of 25 months, ll the fissures heled s did one fistul. However, in six ptients the fistul in no did not hel. Three ptients developed rectl stricture nd 15mO 100/ J. H. Burmn, H. Thompson, W. T. Cooke, nd J. Alexnder Willims in one (cse 11, Tle I) this ws the min indiction for the susequent proctectomy. Furthermore, four ptients who hd initilly not een oserved to hve perinl disese developed fistul in no fter diversion. Creful inquiry into the history efore diversion reveled no evidence of these ptients hving previously hd perinl disese. THE EFFECT OF DIVERSION ON THE DISEASE ACTIVITY OF THE BYPASSED BOWEL The defunctioned owel ws lter excised from 15 ptients fter n intervl of etween two nd 105 months (men 37 months) fter the diversion opertion. The indictions for this susequent resection, together with the opertive nd pthologicl descriptions of the owel removed, re shown in Tle I. In none of the excised specimens ws the defunctioned owel norml. Tle II shows the percentge frequency with which certin histologicl fetures were noted in these 15 cses efore nd fter diversion. While it will e pprecited tht these figures re crude mesurement, nonetheless they confirm the mcroscopic impression tht the defunctioned owel hd not returned to norml. A survey ws then mde of eight of the ptients in whom the rectl remnnt is still retined. Tle III shows the proportionte frequency with which sigmoidoscopic nd iopsy normlities were Fig. 1. Men hemogloin levels in g per 100 ml in ptients efore nd fter diversion of the fecl strem () when prt or ll of the disesed colon ws excised t the time of diversion nd () when no resection ws performed. Gut: first pulished s 10.1136/gut.12.1.11 on 1 Jnury 1971. Downloded from http://gut.mj.com/ on 7 My 2018 y guest. Protected y copyright.
The effects of diversion of intestinl contents on the progress of Crohnt's disese of the lrge owel 5-0 2.5 / Fig. 2. Men serum lumin levels in g per 100 ml efore nd fter diversion of the fecl strem () when prt or ll of the disesed colon ws excised t the time of diversion nd () when no resection ws performed. 350 13 Gut: first pulished s 10.1136/gut.12.1.11 on 1 Jnury 1971. Downloded from http://gut.mj.com/ 250 150 50 Fig. 3. Serum seromucoid levels in mg per 100 ml in ptients efore nd fter diversion of the fecl strem () when prt or ll of the disesed colon ws excised t the time of diversion nd () when no resection ws performed. on 7 My 2018 y guest. Protected y copyright.
14 Ptient 1 94 2 7 3 47 4 22 5 75 6 105 7 47 8 11 9 26 10 30 11 38 12 2 13 17 14 5 15 24 Tle I Time etween Defunction nd Lter Resection (mth) J. H. Burmn, H. Thompson, W. T. Cooke, nd J. Alexnder Willims Resons for Lter Resection Anl stenosis, loss of lood nd pus per rectum Persistent nl nd perinl sepsis, rectovginl fistul Sigmoid colon originlly involved in ileocolic fistul. first stge disconnexion of fistul sigmoid ecme strictured. Sigmoidoplsty filed Developed fistul in no nd rectl stenosis Continued dischrge of pus from rectum. Brium enem showed nrrow indistensile hustrl colon, Sigmoidoscopy showed grnulr oedemtous mucos with purulent exudte (thought to e ulcertive colitis with ssocited risk of crcinom) Loss of pus nd lood per rectum (thought to e ulcertive colitis) Loss of pus nd lood per rectum, plple pelvic mss Filure of perinl lesions to suside Continuing perinl sepsis, loss of pus nd lood from rectum Fistul in no, nl stricture Continued perinl disese, rectl stenosis nd purulent rectl dischrge (thought to e ulcertive colitis) Following restortion of fecl strem severe excertion of rectl disese nd development of fistul t the old colostomy site Recurrence of Crohn's disese round the ileorectl nstomosis site fter restortion of fecl strem Severe recurrence of rectl disese two months fter restortion of fecl strem. Purulent rectl dischrge Rectl nd mucous fistul; dischrge of pus nd lood persisted. Sigmoidoscopy nd rectl iopsy showed ctive disese. Multiple perinl fistule developed fter diversion. Rtionle for the lter resection nd ppernces of the defunctioned lrge owel Anormlity Incidence (%/0) At Diversion Mcroscopic Mucosl ulcertion 100 53 Liner ulcertion 40 13 Colestone mucos 40 13 Bowel wll thickening 70 73 Histologicl Chronic inflmmtory cellulr infiltrtion 80 53 Sumucosl oedem nd firosis 70 47 Crypt scesses 40 40 Epithelil cell follicles 40 20 Gint cells 90 40 Lymph node hyperplsi S0 27 At Resection Tle II Incidence of normlities in 15 ptients found in the colon t the diversion opertion nd susequently t the resection noted efore nd fter diversion. Although there is n overll improvement fter diversion, in none of these ptients were the findings entirely norml in the rested owel. Mcroscopic Description of Defunctioned Bowel t Time of Resection Thick, contrcted colon Moderte serosl inflmmtion, mucosl rugosity nd liner ulcertion, slight rectl pseudopolyposis Externlly norml except for stenosed sigmoid, loss of mucosl pttern t proximl end of specimen with firosis nd superficil ulcertion in rectosigmoid region Thickening nd scrring of colon, mucosl rugosity nd irregulr congestion of rectl mucos Thickened owel wll Thickened sigmoid colon dherent in pelvis Thickened dherent sigmoid colon with thickened mesentery Colon smll nd short, ulcerted mucos throughout colon Thickened colon with widespred mucosl ulcertion Sigmoid fixed in pelvis t old scess site Thickened mesentery nd glnds, thickened colon with loss of hustrtion, widespred mucosl ulcertion Defunctioning ileostomy performed, no colon pthology otined Grossly thickened mesentery nd lymph nodes, thickened oedemtous colon nd ileum, gross mucosl ulcertion Perirectl scess, colon wll thickened, mucos colestoned with pseudo polypi nd ulcertion Thickened contrcted colon, sigmoid fixed in pelvis, mucos ulcerted throughout THE FATE OF DIVERTED BOWEL WHEN RETURNED TO CONTINUITY Five ptients hve hd the owel continuity restored (from etween eight weeks nd 33 months fter diversion). Two re well with no symptoms. Of the remining three, one underwent proctectomy three months lter ecuse of severe recurrent proctitis, Findings No. of Ptients Diversion Sigmoidscopic Rectl stricture 1 4 Mucosl ulcertion 5 7 Mucosl iopsy Chronic inflmmtory cellulr infiltrtion 6 5 Sumucosl oedem nd firosis 5 1 Gint cells 2 1 Diversion' Tle III Sigmoidoscopy nd iopsy findings efore nd fter diversion in eight ptients still retining defunctioned owel 'Men period since diversion 25 months Gut: first pulished s 10.1136/gut.12.1.11 on 1 Jnury 1971. Downloded from http://gut.mj.com/ on 7 My 2018 y guest. Protected y copyright.
The effects of diversion of intestinl contents on the progress of Crohn's disese of the lrge.owel 15 second required n emergency loop ileostomy two months fter ecuse of dirrhoe nd the development of colocutneous fistule, nd the third suffered ill helth for sevenyers, developing fistule oth entero-cutneous nd entero-vesicl, nd eventully died of mesenteric infrction. In the two successful cses recent sigmoidoscopy nd iopsy reveled frile mucos with histologicl evidence of chronic inflmmtory rection. NEOPLASIA Neoplsi hs not een oserved in ny ptient in this survey. Discussion In ll our ptients diversion of the fecl strem wy from n re of ctive colitis hs hd eneficil effect upon the ptient. Their generl helth hs improved nd this hs een orne out y the hemtologicl nd iochemicl evidence. The fct tht similr improvement occurs whether or not the disesed colon is resected suggests tht it is due to the fct tht feces re no longer pssing over the disesed owel. In only two ptients hs restortion of the fecl strem een successful, nd in none hve the histologicl findings t iopsy returned to norml. While it cn e rgued tht slight mucosl ulcertion nd chronic inflmmtory rection re non-specific chnges nd tht these ptients cn e controlled y medicl mens fter restortion of fecl flow, we hve only found this to e prcticle in two (7 %) in our series. Perinl disese hs developed de novo in four ptients fter diversion nd rectl stricture in three others. As result of our experience we feel tht there is only smll chnce tht 'resting' the lrge owel will led to heling in Crohn's colitis sufficient to llow restortion of the fecl strem. Requests for reprints to J.A.W., The Generl Hospitl, Birminghm, B4 6NH. References Oerhelmn, H. A., Jr., Kohtsu, S., Tylor, K. B., nd Kivel, R. M. (1968). Diverting ileostomy in the surgicl mngement of Crohn's disese of the colon. Amer. J. Surg., 115, 231-240. Oerhelmn, H. A., Jr., Kohtsu, S., Tylor, K. B., nd Porteous, J. (1970). Diverting ileostomy for Crohn's disese of the colon. 4th World Congress of Gstroenterology, Copenhgen. Astrcts, p. 231. Truelove, S. C., Ellis, H., nd Wester, C. D. (1965). The plce of doule-rrelled ileostomy in ulcertive colitis nd Crohn's disese of the colon: A preliminry report. Brit. med. J., 1, 150-153. Gut: first pulished s 10.1136/gut.12.1.11 on 1 Jnury 1971. Downloded from http://gut.mj.com/ on 7 My 2018 y guest. Protected y copyright.