Patients and Methods

In a 7-year period, from 1997 to 2004, 13 patients were referred to our surgical department for man-

Table 1. Incidence of inflammatory bowel disease in Italy [39]

UC

CD

Age adjusted incidence

5.2

2.3

rates per 100 000 per year

Rates computed after correcting

6.8

2.8

underestimation

Sex ratio M/F

1.7

1.0

Highest age specific

30-39

20-29

incidence rates

years

years

agement of IBD emergencies (Table 2). Most of them had to be operated on more than once. Patients with ulcerative colitis (UC) or Crohn's disease (CD) admitted for elective surgical procedures as well as those suitable for an ileal pouch-anal anastomosis are not included. The mean age of women (n=6) was 32.5 years, while the mean age of men (n=7) was 46.3 years. Ten patients had CD-associated emergencies, only three had ulcerative colitis. Abscess and fistula formation, associated with sepsis (n=7), were the most frequent emergencies regarding our IBD patients. We emphasise that these patients had to be operated on under general anaesthesia and that those with superficial lesions treated in local anaesthesia and in an ambulatory setting are not included in this group. As a rare occurrence, one patient presented with ulcerative colitis and a giant subhepatic abscess, which could be successfully drained by a transcuta-neous echoguided approach. Another patient presented with a right multiloculated psoas abscess. After successful drainage of the abscess, diagnosis of Crohn's disease of terminal ileum was established. Despite adequate medical therapy, the patient developed another psoas abscess. Therefore, besides abscess drainage, an ileocecal resection was performed. Since then, the patient is doing well. Four patients with CD underwent urgent ileocecal resection for intestinal obstruction. In three of them the obstruction was associated with the abscess formation; in one it was associated with an enteroenteric fistula. In a patient with a descendent colon obstruction due to CD, only a cecostomy was carried out; after 1 year of medical treatment the obstruction resolved and the cecostomy could be closed. Two patients with ileal CD underwent appendectomy without complications. The patient with toxic megacolon underwent colectomy and an ileal pouch-anal anastomosis in another hospital where he was known as an UC patient. Some months later, when the specimen was re-examined by a famous pathologist, the diagnosis of UC was changed to CD. The patient, indeed, developed severe complications caused by the ileal pouch such as diarrhoea, incontinence and perianal fistula.

Table 2. Emergencies in IBD: our experience

Gender Age of patient Diagnosis

Treatment

Results

Male

Female

Female

Male Female

Female Male

Female Female

Male Male

1990: intestinal bleeding (UC)

1993: toxic megacolon Histological diagnosis revisited: Crohn's disease Increasing perianal problems

1998: diagnosis of CD 2GGG: acute appendicitis

1989: diagnosis of CD 1997: fulminant colitis 1999: development of a rectovaginal fistula. Severe perianal CD 2001: duodenal CD

1990: diagnosis of CD 1998: perianal fistula

1995: diagnosis of CD of the small bowel

2000: bowel obstruction

1998: diagnosis of CD 1999: acute appendicitis

1997: diagnosis of CD 2002: anorectal fistula 2004: abscess with bowel obstruction

1989: diagnosis of CD 1998: abscess, enteroenteric fistula and bowel obstruction

2002: psoas abscess (diagnosis of CD)

2002: bowel obstruction 2005: psoas abscess

1999: diagnosis of Crohn's colitis

2003: colonic obstruction

1987: diagnosis of UC 1998: acute colitis 2003: free sigmoid colon perforation

Colectomy, end-ileostomy and mucous fistula. Some months later ileo-anal-pouch

Several operations for perianal- and abdominal-wall fistula

2000: end-ileostomy

Laparoscopic appendectomy

Subtotal colectomy, rectal anastomosis 2GG1: end-ileostomy

Fistulectomy

Ileal resection and anastomosis

Appendectomy

Has mild symptoms of perianal CD and lastly a low output enterocutaneous fistula has developed. General state of health is good

Histologically severe inflamed appendix without specific signs of CD

No further surgical treatment until now

Azothioprin-induced pancreatitis

Improvement of perineal CD, no evidence for recto-vaginal fistula and duodenal CD today

No recurrence of perianal CD

end-to- No further surgical therapy

No further surgical therapy ileo-

Ileocecal resection, abscess drainage relaparotomy for multiple intraperitoneal abscesses 7 days later

1998: ileocecal resection

Drainage, ileocecal resection, re-resection of terminal ileum, abscess drainage

Cecostomy, medical treatment

2004: closure of cecostomy

Left hemicolectomy, end transversostomy, closure of the rectum

Enterocutaneous fistula for 5 months. Actually on medical treatment without complaints

Good state of health without medical treatment, 2 child-births

Actually on medical therapy without complaints

Actually on medical therapy without complaints

No evidence for IBD in the right colon and in the rectum

Abdominal wall rupture, stomal problems, rectal stump failure, sepsis, death after two months of inten-

Male Male

1987 diagnosis of UC 2004: subhepatic abscess

2004: cecal perforation in ileocecal CD and cecal carci-

Percutaneous drainage

Laparoscopic closure of the perforation and biopsy, which revealed carcinoma

Actually on medical therapy without complaints

Died after right hemicolec-tomy in his reference hospital sive care noma

These symptoms could be successfully managed by an ileostomy. Another patient underwent subtotal colectomy and ileo-rectal anastomosis for Crohn's disease. One year later, severe anal CD developed postoperatively with perianal und rectovaginal fistula formation. Additionally, an azathioprine associated pancreatitis and a duodenal manifestation of Crohn's disease impaired the state of health of this young woman. Four years after colectomy, an end-ileostomy was performed and since that time the patient is doing well: she has regained her normal body weight, she is on medical treatment without evidence of duodenal CD and the disastrous perianal situation has improved dramatically showing a disappearance of the rectovaginal fistula. Two patients had free intestinal perforation. The first, a 73-year-old man with UC for 16 years, was referred to our department with free sigmoid colon perforation. The patient was on medical treatment for acute colitis at the medical department of our hospital when he developed multiorgan failure. Interestingly, there was no evidence of toxic megacolon, and free air evidenced on the abdominal plain X-ray was not associated with a classical appearance of acute abdominal pain. The patient was immediately referred to the operating theatre where a large perforation of the sigmoid colon with advanced signs of general peritonitis was found. The right colon, however, and the rectum were free of disease. Therefore, a modified Hartmann's procedure was carried out with resection of the sigmoid colon, closure of the rectal stump and construction of an end-transverse colostomy. After an uneventful postoperative phase of 5 days, a rectal stump insufficiency and an abdominal wall dehiscence had to be repaired twice. Finally, the patient died after 2 months of intensive care treatment. The other patient, a 56-year-old man with CD for more than 10 years, was referred for acute abdomen. This patient also had a long history of duodenal ulcer disease and therefore he underwent laparoscopic exploration. A small perforation of the cecum was found, biopsied, and, because of the absence of typical signs of peritonitis, closed by direct suture. A drain was placed near to the perforation and the postoperative phase was uneventful. Histologic examination of biopsies revealed a carcinoma. The patient underwent a right hemicolectomy some weeks later in his reference hospital, and he died due to anastomotic leakage.

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