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Crohn’s disease of the ascending colon was diagnosed in 1984. The symptoms of abdominal pain and diarrhea were relieved by treatment with prednisolone and sulfasalazine. Five years later, the patient was suffering from episodes of severe abdominal pain, and investigations revealed a long stricture of the ileum and ascending colon (Figure 51.1) associated with a large right-sided abdominal mass.

In 1982 at the age of 9 years, the patient underwent appendectomy for persistent pain in the right iliac fossa. The distal two-thirds of the appendix was described as abnormal with slight enlargement and a vascular reaction on the serosal surface. The terminal 10cm of the ileum was thickened and hyperemic with some fibrin on its surface. The cecum appeared normal. The ileocecal lymph nodes were enlarged. Histological examination of the appendix showed mild nonspecific inflammation. In 1985, the patient was referred with an enterocutaneous fistula that had recently appeared in the appendectomy scar. There was a mass in the right iliac fossa and radiological investigation demonstrated a stricture of the terminal ileum.

The patient was referred for possible surgical treatment in August 1988 with a 12-year history of Crohn’s disease. He had been unwell for 12 months, with an increase in chronic diarrhea, particularly at night (×5). A barium enema showed a “disorganized” colon with shortening, sacculation, and strictures. A colonoscopy was possible only to 30cm (stricture). An anal stricture was present, the mucosa in the mid upper rectum appeared normal, and proximal to this pseudopolyp formation was present. At this time, the patient was unwilling to undergo operation. In March 1992, clinical features of chronic large bowel obstruction were obvious. Investigations of the bowel lumen were limited by an impassible stricture at 30 cm, and a supervening carcinoma could not be excluded (Figure 53.1).

Crohn’s colitis was diagnosed in 1979 at the age of 14 years. It manifested clinically with chronic diarrhea and multiple perineal fistulae, which responded for some years to maintenance therapy with prednisolone. In 1982, a contrast barium enema showed a remarkably shortened colon with sacculation of the transverse colon, “cobblestone” mucosa, incompetent ileocecal valve, and a long stricture of the left colon (Figure 54.1). In 1987, the patient presented with a mass and enterocutaneous fistula in the right iliac fossa. She was markedly small for her age (17 years) with no evidence of sexual development. The perineal disease was quiescent, an anal stricture was present, and the perineum deeply scarred from previous active fistulae. Colonoscopy revealed a shortened colon, (ileocecal valve at 50cm) with a contracted lumen, areas of pseudopolyps, and typical ulceration of Crohn’s disease. X-rays of the small bowel demonstrated a severely distorted terminal ileum, with “cobblestone” mucosa. After a further period of ill health supervened with fevers, weakness, and weight loss, the patient and family agreed to major surgical treatment.

One year after the proctocolectomy for chronic Crohn’s disease of the terminal ileum and colon (see Case 54), the patient was experiencing episodic abdominal pain, fever, and lethargy. A small bowel x-ray showed nodularity of the mucosa throughout its length. A blood count revealed iron deficiency anemia and a raised erythrocyte sedimentation rate (ESR) (85). Steroid therapy was recommenced and continued for 4 months. A remission for 3 years was obtained with this therapy, albeit with occasional abdominal pain and fever. In May 1993, the patient was admitted to hospital with severe abdominal pain, diarrhea, and fever with a palpable mass in the left iliac fossa (LIF). Radiological investigation demonstrated an intraabdominal abscess.

The patient presented with an 18-month history of epigastric and back pain, anorexia, and loss of weight. This was associated with postprandial abdominal distention. His bowel habit was normal. Physical examination revealed a tense palpable cecum. A barium enema showed an unusual extrinsic deformity in the mid transverse colon associated with angulation and narrowing of the colon (Figure 56.1). Carcinoma of the pancreas was considered as a possible diagnosis.

Four years after a bowel resection for Crohn’s disease (Case 56), this patient was admitted to hospital with a 2 week history of lower abdominal pain and alternating diarrhea and constipation. A tender mass was present in the right iliac fossa. A small bowel contrast series showed fixed loops of dilated small bowel indicative of “mild obstruction” (Figure 57.1). Recurrent Crohn’s of the small bowel was diagnosed and treatment with prednisolone initiated. The patient’s reasonable progress over the next 15 years was interrupted by 3 significant episodes of small bowel obstruction. Radiological investigations demonstrated 2 or 3 small bowel strictures with evidence of chronic obstruction (Figure 57.1). Colonoscopy was normal up to and including the ileocecal valve. The patient now agreed to surgical treatment.

In 1976, the patient presented with a 9-month history of diarrhea and anal discharge. Sigmoidoscopy to 20cm revealed an anterior anal fissure and a mild patchy proctitis. A barium enema demonstrated a long stricture of the descending colon with almost complete obstruction “due to advanced Crohn’s disease” (Figure 58.1). Rectal biopsies were consistent with this diagnosis. Over the next 9 months, the patient was treated with oral prednisolone, resulting in intermittent improvement. In April 1977, a cautious barium enema showed persistence of the stricture and gross dilation of the transverse colon (Figure 58.2). Elective operation was arranged but was superceded by urgent admission due to acute bowel obstruction and signs of peritonitis.

Ulcerative colitis had been diagnosed more than 2 years previously. A severe attack of colitis supervened in April 1992, necessitating 2 admissions to the hospital with clinical signs of septicemia and dilatation of the colon. With conservative treatment (steroids) he made very slow progress over a period of 3 months, but was readmitted with abdominal pain and constipation. The patient looked unwell, groaning with pain. There was generalized abdominal distention and tenderness most marked in the right iliac fossa. A plain abdominal x-ray showed dilatation of the colon and a large collection of feces in the right colon. On referral, laparotomy was advised.

This patient underwent urgent laparotomy (February 1989) for toxic megacolon that was initially interpreted as mechanical large bowel obstruction. The surgeon performed a loop colostomy in the transverse colon. The true nature of the disease was revealed with a subsequent colonoscopy, which demonstrated severe colitis from the rectosigmoid to the cecum. The patient made a satisfactory recovery and was referred for further management 6 months after the urgent operation. Colonoscopy revealed an active colitis commencing at the rectosigmoid, with extensive polyposis extending to the transverse colon. The colon proximal to the colostomy was diffusely inflamed without obvious ulceration or polypoid lesions. The mucosa of a large prolapsed transverse colostomy was relatively normal.