two patients with associated toxic megacolon. One patient in this series previously was ..... Ciccarelli 0, Coley GM. Massive rectal bleeding in Crohn's colitis.
Severe Gastrointestinal Hemorrhage in Crohn's Disease
J. R. ROBERT, M.D.,* D. B. SACHAR, M.D.,t and A. J. GREENSTEIN, M.D.*
Twenty-one of fifteen hundred twenty-six patients with Crohn's disease (CD) treated at The Mount Sinai Hospital between 1960 and 1986 developed severe gastrointestinal hemorrhage. There were 26 separate episodes of severe hemorrhage: 17 patients bled only once, three bled twice, and one bled three times. The frequency of bleeding was significantly higher among patients with colonic involvement (17 of 929; 1.9%) than among those with small bowel disease alone (4 of 597; 0.7%) (p < 0.001). Twelve patients required surgery on 13 occasions, which involved colon resection in all but one case. Eleven of these patients underwent surgery during their first hemorrhagic episodes, and 1 of 11 had a second operation for recurrent bleeding; the 12th patient, whose first hemorrhage had been treated medically, had surgery during a repeated episode of hemorrhage. The precise bleeding points could be located in only 2 of the 26 bleeding episodes, both at the ileocecal area. Three patients died, of whom two had not undergone surgery when they had bled a few weeks earlier. Primary bleeding episodes subsided without surgery in 10 of 21 cases, but 3 of these 10 patients (30%) rebled massively. By contrast primary excisional surgery was followed by recurrent hemorrhage in only 1 of 11 cases (9%). These differences in mortality and in recurrent bleeding rates, although not statistically significant, seem to favor removal of diseased bowel at the time of the first episode of massive hemorrhage. S
EVERE GASTROINTESTINAL HEMORRHAGE in Crohn's disease (CD), although not mentioned in the original description of the illness,' is not highly exceptional.2'3 It occurs with approximately the same frequency in all CD cases as in ulcerative colitis (UC),18 ranging in various series from O%9-" to 6%. 12-16 Therapeutic approaches to severe hemorrhage have differed between UC and CD because of the differing longterm outcomes in the two diseases. Colectomy is carried out more readily in UC with the prospect of permanent cure, while a more conservative posture has been adopted for CD because of its proclivity to postoperative recur-
Address reprint requests to Adrian J. Greenstein, M.D., Mount Sinai Medical Center, Department of Surgery Box 1259, One Gustave L. Levy Place, New York, NY 10029. Accepted for publication May 23, 1990.
207
From the Division of Gastroenterology, Departments of Surgery* and Medicine,t Mount Sinai School of Medicine of the City University of New York, New York, New York
rence. This study was undertaken to determine if such moderation in CD is safe and effective.
Material and Methods Between 1960 and 1986, 21 patients with Crohn's disease (CD) were treated at The Mount Sinai Hospital on at least one occasion because of acute severe lower gastrointestinal hemorrhage. The records of20 patients were derived from a retrospective review ofthe hospital records of 1526 patients admitted with CD before 1985, a proportion of 1.3%. The 21st patient was admitted for the first time in May 1986. There were 4 patients with severe hemorrhage among 597 (0.7%) with regional enteritis (RE), 14 among 650 (2.2%) with ileocolitis (IC), and 3 among 279 (1.1%) with Crohn's colitis (CC). Severe hemorrhage was defined as a lower gastrointestinal hemorrhage originating in diseased bowel and requiring at least four units of blood during an interval not exceeding 2 weeks. The diagnosis of Crohn's disease was made by the usual clinical,'7 radiographic,'8 endoscopic,19 and pathologic20 criteria,21'23 including 13 cases in which there were surgical specimens. Twenty-four other patients with severe hemorrhage in Crohn's disease (RE, 10; IC, 6; CC, 8) were excluded from this study for one (or in four cases for two) ofthe following reasons: (a) the source of massive hemorrhage was duodenal ulcer confirmed by gastroscopy and/or surgery (8 patients);" (b) bleeding occurred within 4 to 8 days after surgery or following radiotherapy (3 patients); (c) acute rectal hemorrhage originated from diseased areas of the digestive tract but did not meet our criteria of severity (8
ROBERT, SACHAR, AND GREENSTEIN
208
patients); (c) more than four units of blood were given but blood loss was chronic rather than acute (3 patients); and (e) the episode of hemorrhage occurred outside this institution in patients later seen at The Mount Sinai Hospital for other reasons (6 patients). Comparative statistics were carried out using the chi square
Ann. Surg. * March 1991
INITIAL AND FINAL DIAGNOSIS IN 21 PATIENTS WITH SEVERE HEMORRHAGE IN CROHN'S DISEASE 4
.'
REGINAL ENTERffB .
test.
Results (Table 1)
10
There were 21 patients with severe hemorrhage in CD, men and 10 women, with a mean age of28 years (range, 18 to 48 years; median, 27 years) at the time of the first bleeding episode. The mean duration ofdisease from onset to time of hemorrhage was 6 years (range, 7 weeks to 26 years; median, 5 years). There were 26 episodes of severe hemorrhage: 17 patients bled only once, three bled twice, and one bled three times. Severe bleeding was never the first manifestation of the disease. Twelve patients had surgery on 13 separate occasions: 11 patients came to surgery during their first bleeding episode and 1 of the 11 required a second operation for recurrent bleeding; the 12th patient, whose first hemorrhage had been treated medically, underwent his first operation during a recurrent episode of bleeding. All patients had been treated with prednisone at some time during the course of their disease, but only 10 of 21 were on steroids at the time of the first hemorrhage. There were two patients with associated toxic megacolon. One patient in this series previously was reported in a review of 25 cases of severe hemorrhage in ulcerative colitis7 because the correct diagnosis of CD was not established until 12 months after his bleeding episode.
LEOCOLxIS
0
CROHN'ScaLns
0
ULCERATIVE COLTIS
11
s. 4 FINAL DIAGNOSIS
OVHIUORHMAGE
FIG. 1. Diagnoses of the 21 patients presenting with severe hemorrhage in Crohn's disease, distinguishing those 16 known to be suffering from CD at the time of initial bleeding from five originally diagnosed as having ulcerative colitis.
Differential Diagnosis and Site of Disease (Fig. 1) Sigmoidoscopy, radiology, or pathologic examinations of resected specimens performed at the time of the first severe hemorrhage established the diagnosis of CD in 16 patients (RE, 4; IC, 10; and CC, 2). In the 11 resections for primary hemorrhage, histopathology clearly revealed CD in seven patients (RE, 2; IC, 4; and CC, 1), but the initial pathologic diagnosis was UC in four patients. I1eocolitis was found in both patients with recurrent hemorrhage. Nine of the ten patients with ileocolitis had colonic involvement in continuity with diseased ileum and
TABLE 1. Clinical and Epidemiologic Data of 2I Patients with Severe Hemorrhage in Crohn's Disease
*
was
Data
Male
Female
Number of patients Operated patients Age at onset of disease (years) Median Mean Range Age at time of first hemorrhage (years) Median Mean Range Duration of disease from onset to hemorrhage (years) Median Mean Range First/recurrent hemorrhage Operated/recurrent hemorrhage Nonoperated recurrent hemorrhage
11 5
10 8
21 23.4 14-41
21 20.6 14-38
21 22.0 14-41
28 29.5 18-46
25 26.5 21-48
27 28.0 18-48
5 6.1 7 wks-20 yrs
5 5.9 8 wks-26 yrs 10/1 8/0 2/1
5 6.0 7 wks-26 yrs 20*/4
10*/3 5/1
5*/2
One male patient had massive bleeding previously elsewhere and treated at Mount Sinai Hospital for the recurrent severe bleed.
All Patients
21 13
13t/h
7*/4
t Includes two patients with recurrent hemorrhage and I I with primary hemorrhage.
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SEVERE GASTROINTESTINAL HEMORRHAGE IN CROHN'S DISEASE
extending distally beyond the hepatic flexure (eight of these nine had extensive colitis sparing the rectum); the 10th patient had a normal ascending colon but skip lesions on the left side. For the five patients still labeled UC at the time of initial hemorrhage, the correct diagnosis of CD (CC, 1; IC, 4) was established 1 to 18 years later, following surgery (for 3), barium enema and sigmoidoscopy (for 1), or ileoscopy through ileostomy (for 1). Among all 21 patients with severe hemorrhage, those four who had their inflammatory processes limited to the small bowel were derived from a population of 597 RE patients (0.7%), whereas the 17 with colonic involvement came from 929 IC + CC patients in the total series (1.9%). This higher proportion of cases of severe hemorrhage among the colitis and ileocolitis patients is significant by chi square analysis (p < 0.001) and remains so even after eliminating the five patients who were thought to have UC at the time of initial hemorrhage (12 of 924 or 1.3%; p
