Implications of Involvement of Small Bowel in Ulcerative Colitis*

JAMES BARRON, M.D., LAURENCE S. FALLIS, M . D .

From the Department of Surgery, Henry Ford Hospital, Detroit, Michigan

EXTENSION Of ulcerative colitis from the large intestine into the terminal portion of the ileum has been recognized by many authors. The implication of this associa- tion, however, has not received the empha- sis that it merits. According to Crohn, s an obscure Civil ~vVar surgeon, in 1865, de- scribed the lesions of ulcerative colitis, but credit for the original description usually is given to ~vVilks and Moxon. ~0

Inddence : "vVhite, 9. as early as 1888, ob- served ulceration in the terminal portion of the ileum while performing postmortem examinations on 11 patients who had ulcer- alive colitis. DennisS stated that 33 per cent of his patients with ulcerative colitis treated by surgery had ileal involvement. He advocated removal of a segment of ileum for microscopic examination, since it was often impossible to detect early changes in the ileum by external examina- tion. McCready and associatesS observed this associated involvement in cases of ulcer- ative colitis. They stated that surgery should not be pertormed unless the resec- tion could include that portion of the ileum situated well above the gross and micro- scopic involvement. Thei r material con- sisted of specimens removed from 29 pa- tients (28 per cent) with ileal involvement in 81 autopsy and 22 surgical specimens. Bacon 1 found considerable variation (1.3 to 42.3 per cent) in the incidence of ileal involvement. The trend suggests that the longer the period covered and the more intensive tt~e study, the greater wiii be the number of recognized cases (Table 1).

*" Read at the meeting of the American Procto- logic Society, San Francisco, California, May 20 to 23, 1963.

Counsell 4 reported 17 per cent retrograde ileitis in cases of ulcerative colitis after a careful pathologic study at St. Mark's Hos- pital in London. He believed that ileitis will heal after colectomy and ileostomy, or ileostomy alone, and that even when made in a diseased area, no harm will result. This observation is contrary to our own and the experience ot" others. Some of the discrepancy in the reports of the incidence rate may be explained on the basis of the controversy regarding ileocolitis as a clini- cal entity, as maintained by Brooke,.; and by the inclusion by some authors of ileal lesions produced by ileostomy dysfunction. Many of these patients present serious be- havior problems, often manifested by re- fusal to eat. Therefore, the importance of maintaining nutrit ion by forced tube feed- ing 2 after operation cannot be overempha- sized, since starvation alone can produce small intestinal ulceration. Another source of statistical error is the coexistence of regional ileitis and ulcerative colitis in the same patient. Right-sided colitis carries a higher incidence of ileal involvement and, in many ways, seems to occupy a mid posi- tion between ulcerative colitis and regional enteritis, both clinically and pathologically. Brooke a stresses the importance of ileo- colitis as a separate entity and warns that ileostomy is not the best treatment in this particular group due to the possibility of recurrence above the ileostomy. Not all attthorities agree with Brooke ,3 and, as Goiigher7 points out, tllere is stit! consider- able discussion as to the exact status of ileocolitis. It may be concluded, however, that the classic concept of ulcerative colitis or regional enteritis, terminating at the ileo-

290

SMALL BO~,VEL IN ULCERATIVE COLITIS 2 9 l

cecal valve, is no longer valid, for it is now general ly recognized that the i leocecal valve

presents no bar r ie r to extens ion of the dis- ease. T h e final answer to all of these ques- tions probab ly mus t await discovery of the true etiology of regional enter i t is a n d ulcerat ive colitis.

Materia l Studied: T h e deve lopmen t of

serious operat ive compl ica t ions and post- operat ive sequelae, in some of our pa t ien ts who u n d e r w e n t total colectomy and who

had concur ren t ileal invo lvement , s t imu-

lated us to review our ent i re recent experi- ence. T h e mater ia l s tudied was taken f rom the records of 99 pa t ients who u n d e r w e n t

opera t ion for advanced ulcerat ive colitis. None of the cases of known regional en-

teritis or of i leostomy dysfunc t ion has been included. In this g roup ol" 99 patients , 29

(29.3 per cent) had varying degrees of in- vo lvement of the small bowel. X-ray exami-

na t i on showed 0nly the more severe degrees of ileal i nvo lvemen t and, in general , t ended to min imize the true ex ten t o1~ the disease in the small bowel. Most pat ients wi th

ileal i nvo lvemen t did not have extensive pseudopolyposis.

Age: As one would expect, the most com- mon and often most serious disease occurs in the lower age groups; 75 per cent of the

pat ients were 10 to 40 years of age and 25 per cent were more than 40 years old.

T..~.I~LE I. DIcidence

Author °7 / o

Bacon 42.3 Crandon and associates 39 l)ennis 33 Authors' series 29 McCready and associates 28 McMillan 25 Brooke 25 Crohn 2~ Cattell 20 Ca ve 10 Crohn and Garlock 8 Bargen and Weber 6.3 McKittrick and Miller 1.3

].'aBLE 2. Operations Performed

Ileorectostomy 11 Proctocolectomy 9

Ileostomy 5

Partial colectomy and ileostomy 3

Ileocolostomv 1

Durat ion: T h e d u r a t i o n of the disease

appeared to have no defini te r e la t ionsh ip to invo lvement of the small bowel, for 51

per cent of our pat ients had the disease less than three years a nd 49 per cent had

suffered from five to 15 years.

R e c o g n i t i o n of I l ea l I n v o l v e m e n t at Opera t ion : Al! 99 pat ients opera ted u p o n u n d e r w e n t surgical i n t e r v e n t i o n only after fa i lure o[ medical m a n a g e m e n t in the acute cases, or because ol/ compl ica t ions in the

chronic cases, i leal i n v o l v e m e n t was even- tual ly discovered in 29 of the 99 pat ients ,

bu t in only ten was the cond i t i on discov- ered by the surgeon pr ior to the operat ion.

In our experience, visual inspec t ion o[ the opened i l eum is sufficient a nd we have not

found it necessary to employ frozen sections

as advocated by Dennis a n d others. T h e r ema inde r were recognized e i ther by exami- na t i on of the removed segment of i l eum d u r i n g the surgical procedure, or by the

deve lopment of symptoms at a la ter date in pat ients in whom no par t o[ the i l eum was removed. T h i s observat ion emphasizes

the necessity for inspect ion of the open i leum at the t ime of opera t ion , since in two thirds otZ the cases, gross inspec t ion and

x-ray e x a m i n a t i o n were insufficient to re- veal that there was mucosal involvement .

TABLE 3. ~Iorta[it 7

Operative Death Type of operation No. death later

~Tieorectostomv t i 0 2 Proctocolectomy 9 0 I IIeostomv 5 1 4 Partial colectomv and 3 0 3

ileostomy Ileocolostorny 1 0 0

292 BARRON AND FALLIS

T y p e of O p e r a t i o n

T h e surgical p rocedures p e r f o r m e d on the 29 pa t i en t s are l i s ted in T a b l e 2. T w e n t y of the 29 pa t i en t s u n d e r w e n t to ta l co lec tomy, 11 wi th i l eorec ta l anas tomos is and n ine wi th to ta l r emova l of the r e c t u m a n d p e r m a n e n t ileostomyo T h e r e were no opera t ive dea ths in this g roup , b u t two pa t ien t s d i ed subsequen t ly f rom compl ica- t ions caused by r e c u r r e n t ileitis. T h e five i leos tomies were p e r f o r m e d wi th the p a t i e n t u n d e r the inf luence of local anes thes ia ; the pa t ien t s were in ex t remis a n d u n a b l e to w i th s t and bowel resect ion. One d i ed seven days af te r o p e r a t i o n f rom u n c o n t r o l l a b l e loss of fluid. At p o s t m o r t e m e x a m i n a t i o n , ulcers were f o u n d t h r o u g h o u t the en t i r e i leum. T h e lone surv ivor of this g r o u p con- t inues to be wel l af ter i leorec tos tomy, b u t the r e m a i n i n g three pa t i en t s d i ed w i t h i n two years.

c ompa ra b l e g r o u p o[ 77 p a t i e n t s w i t h o u t i leal i nvo lvemen t showed fou r dea ths (5.7 pe r cent) w i th in a two-year pe r iod . T h u s , in our pa t ien ts the over-a l l m o r t a l i t y ra te was five t imes as g rea t i n pa t i en t s wi th associated i lea l lesions.

Summary and Conclusions

In a series of 99 p a t i e n t s o p e r a t e d u p o n for u lcera t ive colit is, 29 h a d i lea l involve- merit . X-ray e x a m i n a t i o n is no t of g rea t d iagnos t ic value.

At ope ra t ion , gross e x t e r n a l ev idence of i leal i nvo lvemen t was p r e s e n t in only one th i rd of the pa t ien ts . I n s p e c t i o n of the o p e n e d i l eum d u r i n g surg ica l exposu re is ma nda to ry .

T h e long-range m o r t a l i t y ra te was five times greater in pa t i en t s w i t h i lea l involve- m e n t than in those in w h o m the smal l in- test ine was not involved .

R e c u r r e n c e a f t e r O p e r a t i o n

Eight of the 28 pa t ien ts who surv ived o p e r a t i o n r e q u i r e d fu r the r i lea l resec t ion and of these, four have h a d two resect ions each. T h r e e of the recur rences were in pa t ien t s who had i leorectos tomies . In one, the diseased p o r t i o n of the i l e u m was re- moved wi th successful r e -es t ab l i shment of i leorecta l con t inu i ty . T h e o the r two pa- t ients r e q u i r e d i leos tomy. Bo th d i ed sub- sequent ly , one of m u l t i p l e i lea l per fora- tions and the o the r of hepat i t i s . T h e s e two pa t ien ts are the only fa i lures to da te in over 50 i leorec tos tomies p e r f o r m e d d u r i n g the past five years.

M o r t a l i t y a n d M o r b i d i t y R a t e s

T h e seriousness of c o n c o m i t a n t i l e a l in- vo lvemen t in u lcera t ive coli t is is shown in T a b l e 3. T h e ope ra t ive m o r t a l i t y ra te is weli w i th in accep tab le l imits , bu t the long- range fate of these pa t i en t s is dep lo rab l e . One pos tope ra t i ve d e a t h and n ine deaths , w i th in a two-year per iod , give an over-al l m o r t a l i t y ra te of 81 per cent. S tudy of a

R e f e r e n c e s

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2. Barron, J.: Tube feeding of postoperative pa- tients. S. Clin. North America. 39: 1481, 1959.

3. Brooke, B. N.: Ulcerative colitis and its sur- gical treatment. Edinhurgh, E. & S. Living- stone, Ltd., 1954, 147 pp.

4. CounselI, B.: Lesions of the ileum associated with ulcerative colitis. Brit. J. Surg. 44: 276, 1956.

5. Crohn, B. B.: An historic note on ulcerative colitis. Gastroenterology. 42:366, 1962.

6. Dennis, C.: Ileostoiny and colectomy in chronic ulcerative colitis. Surgery. 18: 435, 1945.

7. Goligher, J. C.: Surgery of the Anus, Rectum and Colon. Springfield, Illinois, Charles C Thomas, Puhlisher, 196!, 828 pp.

8. McCready, F. j., J. A. Bargen, M. B. Dockerty and J. M. Waugh: Involvement of the ileum in chronic ulcerative colitis. New England J. Med. 240: 119, 1949.

9. W'hi~e, ~g. H.: On simpie uicerative colitis and other rare intestinal ulcers. Guy's Hosp. Rep. 30 (series 3) : 131, 1888.

10. Wilks, S. and W. Moxon: Lectures on Patho- logic Anatomy. Ed. 2, London, J. & A. Churchill, Ltd., 1875, p. 672.