Idiopathic Proctocolitis Research Articles

Surgical therapy of chronic inflammatory bowel disease in childhood

The overall impression gained from the experience of the Departments of Paediatric Gastroenterology and Surgery attached to St Bartholomew's Hospital are the enormous benefits that surgery has to confer on the large percentage of children with both Crohn's disease and idiopathic proctocolitis who require it. The surgical procedures described in this chapter have been accompanied by a remarkably low complication rate, dispelling the impression that morbidity in such cases would be high. This must in large measure be due to the fact that the children who come to surgery are in as good a state of nutrition as can be achieved by means of the various forms of enteral and parenteral feeding now available. Anxiety about healing of anastomoses and the development of fistulas after surgery for example, has not been a feature of the surgical care of these patients. The principal benefit of surgery has been a clear demonstration of an improvement in growth velocity in both Crohn's disease and idiopathic proctocolitis patients provided always that surgery is correctly timed. It is the author's experience that maximum benefit is achieved if the bulk of the diseased bowel can be removed. Plainly relief of symptoms such as abdominal pain and diarrhoea has also been rewarding. In many instances second procedures such as restorative proctectomy in idiopathic proctocolitis can be timed to fit in with educational commitments. In Crohn's disease the likelihood of recurrence in adult life is high but these patients are in a fit state to cope with further therapy including surgery should the need arise. From the management point of view the close cooperation between physicians and surgeons at all stages has been crucial, firstly to achieve smooth preparation prior to surgery and satisfactory after care. But of even more importance in the assessment of Crohn's disease is the presence of all clinicians involved in the case in the operating theatre so that the surgical options are fully assessed. This united approach avoids any unnecessary anxiety when, as inevitably happens, recurrence of symptoms due to relapse occurs. The involvement of patients of whatever age, and parents in all the decision making processes from the time of diagnosis has been vital. Early discussion about stomas involving members of the Stomatherapy Department has been invaluable. One final important aspect of the management of these patients is the seamless hand-over of care to an adult combined medical and surgical clinic at an appropriate time, usually at the age of 17 years.(ABSTRACT TRUNCATED AT 400 WORDS)

Incidence of colorectal cancer in proctocolitis: a retrospective study of 959 cases over 40 years.

The incidence of colorectal cancer was studied by the actuarial method in 959 patients with idiopathic proctocolitis seen from 1942 to 1981. Forty five per cent had rectal, 23% left-sided, and 32% total involvement of the colon. Six cancers were found: one in the rectal, one in the left-sided, and four in the total form of the disease. The risk of cancer per patient year in total colitis was zero per 2151 patient years in the first decade, 1/462 in the second decade, 1/315 in the third decade, and 1/75 in the fourth decade. The cumulative risk of developing cancer was zero at 10 years of duration of the disease, approximately 5% at 20 years, 15% at 30 years, and 20% at 35 years. This increase in risk of cancer is less than reported in some other series. Geographical differences in the incidence of cancer in proctocolitis could influence the risk and therefore also the long-term management of patients with proctocolitis in different geographical areas.

Rectally administered prednisolone--evidence for a predominantly local action.

Plasma prednisolone levels have been compared in healthy volunteers and in patients suffering from idiopathic proctocolitis after the administration of standard retention enemata containing either prednisolone-21-phosphate or prednisolone metasulphobenzoate sodium. The levels were significantly lower after the latter, irrespective of the presence or degree of activity of the disease. Prednisolone metasulphobenzoate appeared to be as effective as the 21-phosphate ester for the treatment of proctocolitis in the few patients where the two drugs were compared. It seems possible that the beneficial effect of the form of therapy is exerted predominantly locally, rather than by systemic action.

Plasma prednisolone levels and adrenocortical responsiveness after administration of prednisolone-21-phosphate as a retention enema.

Plasma prednisolone levels have been measured by radioimmunoassay after oral and rectal administration to healthy volunteers and to patients with idiopathic proctocolitis. The amount of prednisolone absorbed from a 20 mg retention enema given to patients with proctocolitis was about 44% of that absorbed from the same dose orally administered. Adrenocortical response to synthetic ACTH in patients receiving prolonged rectal therapy was either normal, or only slightly impaired, and this may be related to the pattern of steroid absorption rather than to the total amount absorbed.

The Clinical Presentation and Progress of Inflammatory Bowel Disease

rectal bleed~ng but without diarrhoea, these are mostly patients with proctitis. Full e~amination, sigmoidoscopy and biopsy and barium enema w~n be required. Patients with anal lesions, a normal reotum or localised les/ions with ukeI'3!tion are classified as likely to have Orohn's disease. Those with n'O anal lesion, a diffusely granular rectum and either a normal or diffusely abnOl'mal sigmoid or colon on barium enema are called idiopathic proctocolitis. 'rhe problem that must be emphasised is that this second group cannot be definitely diagnosed without rectal biopsy and follow up. The presence of a single gmnuloma is enough to change the diagnosis to Crohn's disease, follow up may also change the diagnosis and occ~siona11y examination of a coJectomy spedimen may alter the diagnosi,s. Hence the need for rectal biopsy at every stage of the disease. 2. "Classical" Crohn's disease. A truogy of abdominal pain, diarrhaea and weight lass is narmally present. If the patient has an abdominal mass and an anal lesian the diagnasis can be made with some canfidence. Sa the recognition 'Of anal lesions is all important, particuIarly as many are surprisingly pain-free sa that the patient describes them as piles or is unaW3!re 'Of their presence. Crohn's anal lesians 3!re either a fissure 'Or a fistula, ocoasianalJy a diffuse inflammation and oedema of the anus is the sole finding. The lesions have a char­ acter;istic cyanotic calaur but as with the rectal findings shauld always be can­ firmed by histalagy if the diagnasis has nQ!t been made. Intestinal disease is a11ten acoampanied by ('Or may ocoasional1y present with) malabsarptian, chranic obstruction, interna,l and external fistulae and protein losing enteropathy. A discussion 'Of all these camplications is beyond the scope of this presentatian. 3. Duodenal Crohn's disease. It is naw well recagnised that Cmhn's disease may be a widespread abnormality in the small and large intestine even though the obvious manifestations are local. Duodenal Orohn's disease is yet another lacal lesion. this may present with dyspepsia and radiolagical and endoscopic abnormal,ities and is sometimes misdiagnosed as duodenal ulcer. Hawever systemic illness and anaemia should alert the clinioian. Furthermore the endosoopic appear­ ance may be more diffuse than simple uloeration with a oobblestane mucosal ~l,ange and multiple ulcers.

Salt-losing diarrhoea in idiopathic proctocolitis.

The faecal output of chloride, sodium and potassium was studied in 14 patients with active idiopathic proctocolitis, in an attempt to establish a relationship between faecal electrolyte output and acid-base balance data. 7 patients with ileostomy and 8 healthy volunteers were used as controls. The daily faecal excretion of chloride and sodium in proctocolitis was significantly in excess of normal, whereas that of potassium was within the normal range. From the comparison with the results in patients with ileostomy it is concluded that colitic colon has an impaired capacity to absorb chloride and sodium but retains the ability to secrete potassium. The intestinal loss of chloride in addition to that of sodium and water may be regarded as a salt-losing diarrhoea and may account for the metabolic alkalosis commonly found in proctocolitis.

Blood pH: a test for assessment of severity in proctocolitis.

Acid base balance was studied in 58 patients with active idiopathic proctocolitis; the condition of 10 of them was complicated by toxic megacolon. Arterial blood pH increased progressively with increased severity of the colitis and as the lesions became more widespread. Statistically significant differences were observed in pH values between the mild/moderate and severe forms and between the severe and complicated forms ('toxic megacolon'). A linear correlation was found between pH and the amount of intestinal gas, pulse rate, and plasma albumin.

Crohn's Disease, Non-specific Ulcers of the Small Intestine, and Idiopathic Proctocolitis in a Japanese University Hospital from 1954 to 1974

Most of the cases of Crohn's disease reported in Japan were originally treated surgically as acute appendicitis and, after appendectomy, they were diagnosed as acute terminal ileitis or acute Crohn's disease, which should belong to a category different from typical Crohn's disease, according to the international nomenclature by the Council for International Organization of Medical Sciences in 1973. Reviewing our university hospital records from 1954 to 1974, the incidence of typical Crohn's disease and idiopathic proctocolitis has been increasing, while the patients with intestinal tuberculosis have been decreasing. Clinical and histopathological features of operated three groups of our patients with Crohn's disease of the small intestine, non-specific ulcers of the small intestine and prestomal ileitis were comparatively studied. Furthermore, 9 cases of operated Crohn's disease of the colon and 23 cases of operated idiopathic proctocolitis were similarly evaluated. The importance of diagnosing Crohn's disease as a whole from both clinical and histopathological stand points of view was emphasized, and main differential diagnostic criteria between Crohn's disease and idiopathic proctocolitis were discussed.

Recurrent aphthae: treatment with vitamin B12, folic acid, and iron.

A series of 130 consecutive outpatients with recurrent aphthous stomatitis were screened at the oral medicine department, Glasgow Dental Hospital, for deficienciesin vitamin b12, folic acid, and iron. In 23 patients (17.7%) such deficiencies werefound; five were deficient in vitamin B12, seven in folic acid, and 15 in iron. Four had more than one deficiency. Out of 130 controls matched for age and sex 11 (8.5%) were found to have deficiencies. The 23 deficient patients with recurrent aphthaewere treated with specific replacement therapy, and all 130 patients were followed up for at least one year. Of the 23 patients on replacement therapy 15 showed complete remission of ulceration and eight definite improvement. Of the 107 patientswith no deficiency receiving local symptomatic treatment only 33 had a remission or wereimproved. This difference was significant (P less than 0.001). Most patients withproved vitamin B12 or folic acid deficiency improved rapidly on replacement therapy;those with iron deficiency showed a less dramatic response. The 23 deficient patientswere further investigated to determine the cause of their deficiencies and detect the presence of any associated conditions. Four were found to have Addisonian perniciousanaemia. Seven had a malabsorption syndrome, which in five proved to be a gluten-induced enteropathy. In addition, there were single patients with idiopathic proctocolitis, diverticular disease of the colon, regional enterocolitis, and adenocarcinoma of thecaecum. We suggest that the high incidence of deficiencies found in this series andthe good response to replacement therapy shows the need for haematological screening of such patients.

A double-blind comparison of the effectiveness of azathioprine and sulfasalazine in idiopathic proctocolitis

A double-blind comparison of the effectiveness of azathioprine and sulfasalazine in idiopathic proctocolitis

Observations on idiopathic proctitis

This paper presents the natural history of idiopathic proctitis and concludes that this disease and idiopathic procto-colitis are two manifestations of one disease differing only in the extent of the colon involved.