Crohn’s Disease: Aetiology, clinical manifestations and management PDF
Preview Crohn’s Disease: Aetiology, clinical manifestations and management
Crohn's Disease Aetiology, clinical manifestations and management Dr Burrill B. Crohn CROHN'S DISEASE Aetiology, clinical manifestations and management Bryan N. Brooke, M.D., M.chir., F.R.c.s., F.R.A.C.s. Emeritus Professor of Surgery, StGeorge's Hospital, London and Consultant Surgeon, StJames' Hospital, London David R. Cave, Ph. D., M.R.C.P. Gastroenterology Department, University of Chicago, Illinois John F. Gurry, F.R.C.S., F.R.A.c.s. Department of Surgery, Toronto Western Hospital, Canada Denis W. King, F.R.A.c.s. Senior Surgical Registrar, St George's Hospital, Kogarah. New South Wales © Bryan N. Brooke, David R. Cave, 1977 © John F. Gurry and Denis W. King, 1977 Softcover reprint of the hardcover 1st edition 1977 978-0-333-21560-9 All rights reserved. No part of this publication may be reproduced or transmitted, in any form or by any means, without permission. First published 1977 by THE MACMILLAN PRESS LTD London and Basingstoke Associated companies in New York Dublin Melbourne Johannesburg and Delhi ISBN 978-1-349-03247-1 ISBN 978-1-349-03245-7 (eBook) DOI 10.1007/978-1-349-03245-7 This book is sold subject to the standard conditions of the Net Book Agreement To our old friend and mentor Dr Burrill B. Crohn Contents Preface IX 1 Aetiology 1 2 Genetics 14 3 Epidemiology 19 4 Clinical features 26 5 Acute complications of Crohn's disease 43 6 Diagnosis 56 7 Management 76 8 Azathioprine 83 References 94 Index Ill Preface Throughout the last 30 years I have been associated with patients suffering from Crohn's disease; during this time it has been expanding so that it now bids fair to become the new scourge of the not too distant future: it was a rarity, now it is not. Incontrovertible evidence is to hand revealing a real increase in incidence. Moreover, there are indications that the virulence is increasing: by which I mean not only that the disease appears now to burn more rapidly in those it afflicts but also an inexorability towards both recurrence and complications. Over and against this there is no effective means of control. I must confess to ever-deepening pessimism for if the initiating cause is a virus, and our experimental work would seem to suggest this, it is possible that it appeared, may be as a mutant, and started its career in the last century. Study of the pathological descriptions by Wilks and Moxon (1875) of ulcerative colitis suggests that some of the specimens were anachronistically Crohn's disease; clinical descriptions began to appear (Dalziel, 1913) just after the turn of the century and the increasing appearance of the disease since the seminal description by Crohn, Ginzburg and Oppenheimer (1932) we now know is not solely due to increasing recognition. If there is an infective agent, then it has a slow incubation period, as our experimental studies indicate. The appearance of the disease in man would then be subject almost to geometrical progression. That is why the future looks serious. And that is why this book has been written; for though all are aware of the difficulty of management of the disease the possible future implications are less well appreciated. We wish to alert our profession to the urgent need for a concentration of mind and resources on the problems of both aetiology and management. We hope to render some assistance by setting out our own experience in the investigative field, in clinical assessment and in manage ment, so that anyone who may have to treat patients with Crohn's disease can find helpful guidance here. The book, therefore, is short, written to be read consecutively and yet arranged so that recourse to it for information on any particular facet can be obtained easily. Textual brevity for easier reading has been obtained by wide reference to the literature with the added gain, we X Preface hope, that the bibliography will assist those who need to search more deeply. Though much of what is contained in this book is based on experience gained in the Midlands and in London, the figures are based on a group of 112 patients who have come under our care between 1963 and 1975 in the metropolitan area. We wish to thank Miss Julie Takis for her considerable help in preparing the work and compiling the bibliography. Bryan N. Brooke Department of Surgery StGeorge's Hospital 1 . Aetiology Crohn's disease presents one of the major challenges to contemporary gastroenterology. The disease is a source of continuing morbidity and mortality and is possibly increasing in frequency; in the absence of knowledge of its aetiology, treatment is largely empirical and palliative. Before considering the various approaches used in attempting to elucidate the aetiology of Crohn's disease, a brief historical review is presented in order to provide perspective. A generally accepted clinicopathological definition of the disease can then be derived. HISTORY It is probable that Morgagni (1769) in his work De Sedibus et Causis Morborum gave the first clinical description of a case of Crohn's disease. No reference was made to Crohn's disease in the Medical and Surgical History of the Rebellion U.S.A. (Union Army Medical Corps, 1865), in which the first clinical and pathological description of ulcerative colitis was made, and it was not until 1909 that Braun described several cases of inflammatory masses involving the small intestine. Dalziel ( 1913) reported in detail6 cases similar to those of Braun in which tuberculosis was excluded by careful bacteriological studies. This evoked some acceptance that a benign, chronic, granulomatous condition of the small intestine existed which was not tuberculosis. Crohn, Ginzburg and Oppenheimer ( 1932) in their seminal description of what is now called Crohn's disease focussed attention on a granulomatous disease involving the small intestine. They described 14 cases in a paper read to the American Medical Association entitled 'Regional ileitis: a clinical and pathological entity'. The term regional ileitis was modified after discussion with Dr Bargen who suggested that regional enteritis would be more appropriate since the condition might not be limited to the ileum. DEFINITION In this book the term Crohn's disease will be used since the eponym is generally accepted in the United Kingdom. Fielding (1972), reviewing the
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