1976, British Journal of Radiology, 49, 926-929
Effect of Crohn's disease on colonic diverticula By F. R. Berridge, M.B., F.R.C.P., F.R.C.R., and A. P. Dick, M.D., F.R.C.P. Departments of Radiology and Medical Gastroenterology, Addenbrooke's Hospital, Cambridge {Received January, 1976 and in revised form May, 1976) ABSTRACT
Fifteen cases in which the same part of the colon has been affected by both diverticular disease and Crohn's disease have been studied. When Crohn's disease affects an area of colon where diverticula are present, radiological examination may show a diminution in number or disappearance of the diverticula with progress of the Crohn's disease. With improvement in the Crohn's disease diverticula may appear.
Colonic diverticulosis is most often seen after the age of 50. Crohn's disease of the colon occurs not infrequently in the same age-group, so their occasional association is to be expected. Indeed, Crohn's disease affecting the distal colon has been observed to be particulary common in the elderly (LockhartMummery, 1972). The differentiation between Crohn's disease and diverticular disease, or the recognition that both are present, is clearly of vital importance in reaching decisions regarding treatment and may at times cause considerable difficulty (Schmidt et al, 1968; Marshak et al., 1970). The object of this study is to draw attention to a point of relevance to this problem. It has been observed that a length of colon found to be involved with diverticular disease on radiological examination may later show no diverticula, or a reduced number, when the same area is subsequently affected by Crohn's disease. Conversely, when Crohn's disease has improved, the appearance of diverticula has been noted. CLINICAL MATERIAL
Fifteen cases, in whom diverticular disease and Crohn's disease affected the same segment of colon, have been studied. There were four men and 11 women. Their ages ranged from 47 to 80 with a mean of 67. All except two were over 60. Apart from clinical and radiological evidence, the presence of Crohn's disease was established by a positive rectal biopsy with granulomata in seven. In two cases the rectal biopsy showed non-specific inflammatory changes, but the radiological picture was typical of Crohn's disease. Pathological examination of colectomy specimens in four further cases gave unequivocal evidence, while in another postmortem examination later confirmed granulomatous colitis. There was one patient who had been treated with azathioprine, where histological examination of the excised colon left the distinction between ulcerative colitis and Crohn's disease in doubt. However,
previous radiology had shown a long stricture with a communicating intramural sinus, rose-thorn ulcers and a recto-vaginal fistula. Of the four men, three had disease confined to the distal colon and rectum. In the fourth the distal colon was involved when the patient was first seen, but subsequently the disease spread to involve the whole colon and terminal ileum. Of the 11 women one had involvement of most of the colon and terminal ileum, two had a total colitis, four had left-sided colitis and four a distal colitis. Seven of the 11 women had anal lesions and two of the four men, but their presence was not correlated with the severity of the disease. The duration of the disease at the time the first barium enema was carried out was relatively brief, being six weeks or less in eight of the cases while the others had had symptoms for varying intervals up to 18 months.
RESULTS
Two of the patients had only one barium enema performed and are included for the sake of completeness. The remaining 13 cases had more than one examination and these can be divided into four groups: (A) No change in the diverticula when the Crohn's disease spread to involve the part of the bowel where the diverticula were situated—two cases. (B) The diverticula diminished in number when the Crohn's disease involved the segment of the bowel previously affected by diverticula—six cases. (C) The diverticula disappeared completely when the affected part of the bowel became involved with Crohn's disease—three cases. In one of these patients the diverticula subsequently reappeared when the Crohn's disease had become quiescent following a defunctioning ileostomy. (D) Following the subsidence of Crohn's disease diverticula appeared in an area of bowel previously affected by Crohn's disease—two cases. It is not known whether symptomless diverticulosis had been present in these two cases before the development of Crohn's disease.
926
NOVEMBER
1976
Effect of Crohn's disease on colonic diverticula CASE HISTORIES
Case! This 61-year-old housewife gave a six month history of worsening diarrhoea, latterly with blood in the stools, and two stone weight loss. Examination revealed a thin, pale, anxious woman. Anal skin tags were present. Haemoglobin 9 g.%. Sigmoidoscopy, under anaesthesia, showed reddening and irregular granularity of the rectal mucosa. Histology of rectal biopsies showed non-specific inflammatory changes.
Barium enema (27.2.59) showed narrowing and deep ulcers in the upper descending colon and the distal transverse colon. On the pelvic and iliac colon there were multiple diverticula (Fig. 1, a and b). Treatment with intramuscular corticotrophin gel was followed by considerable symptomatic improvement, but the patient returned five months later with a relapse, At this time sigmoidoscopy showed similar changes but histology on this occasion revealed the presence of granulomata. Cortico-steroids resulted in a remission but relapse occurred after three months. A barium enema at this time (18.3.60) showed extension of the disease proximally to the mid-transverse colon, where there were undermined ulcers, and distally to the iliac and pelvic colon where typical hyphen ulcers (Berridge, 1975) were seen. The descending colon was devoid of haustration. The affected part of the colon and rectum were narrowed and the post-rectal space increased. The diverticula, which had been present on the pelvic and iliac colon, had disappeared (Fig. 2, a and b). Progress was less satisfactory on further treatment with cortisone, and colectomy and ileostomy were performed four months later. The resected specimen showed Crohn's disease involving the caecum and the whole of the remainder of the colon, apart from the lowermost 10 cm of the ascending colon. No diverticula were present in the specimen. Case 2
A 49-year-old housewife presented with four months history of constipation with blood and slime in the stools. A diffusely reddened and oedematous mucosa was seen on sigmoidoscopy. Barium enema (5.1.65) showed diverticula on the distal transverse colon, descending colon and pelvic colon, but no other abnormality (Fig. 3). Treatment with sulphasalazine and courses of prednisolone retention enemata was followed by some improvement. Two years
FIG. 1. Case 1. 27.2.59. (A) Narrowing of the distal transverse colon. Diverticula on the descending and iliac parts of the colon. (B) Diverticula on the pelvic colon.
927
VOL.
49, No. 587 F. R. Berridge and A. P. Dick after the onset she developed an arthritis in several finger joints and a painful sacro-iliitis. At that time, barium enema (15.2.67) showed a few diverticula on the pelvic colon only and some narrowing of the rectum (Fig. 4). The joint symptoms subsided on treatment but shortly after this the picture changed with the development of diarrhoea, anal skin tags and an irregular cobblestone appearance in the inflamed rectum. Rectal biopsy showed non-specific inflammatory changes. Local steroid therapy produced some improvement but 18 months later she developed worsening diarrhoea and progressive anaemia, requiring transfusion. Barium enema (18.11.68) showed narrowing of the rectum and a cobblestone mucosal pattern
FIG. 3. Case 2. 5.1.65. Diverticula on the whole of the left side of the colon.
FIG. 2. Case 1. 18.3.60. (A) The diverticula on the descending and iliac colon no longer seen. Hyphen ulcers on the iliac colon. (B) Deep ulcers on the pelvic colon.
FIG. 4. Case 2. 13.2.67. Fewer diverticula now seen and only on the pelvic colon.
928
NOVEMBER 1976
Effect of Crohn's disease on colonic diverticula in the pelvic colon with a few deep ulcers. The diverticula in being removed. The wall of the ileum showed typical the pelvic colon had completely disappeared (Fig. 5). changes of Crohn's disease while throughout the colon there Shortly after this examination the patient became distended were scattered areas of mucosal ulceration and pseudoand laparotomy was performed. The pelvic colon was polyp formation, with extensive ulceration in the anal region. diffusely indurated and oedematous and the whole colon distended. An ileostomy was carried out. DISCUSSION Following this her general condition improved considerably. Barium enema (9.1.69) carried out on the defunctioned The association of diverticular disease and Crohn's colon showed a return of the diverticula in the pelvic colon disease in the same segment of colon is of considerand the cobblestone appearance of the mucosa could no longer be demonstrated (Fig. 6). Procto-colectomy was able interest. Although the establishment of the subsequently performed on 13.1.69, 8 cm of ileum also diagnosis of diverticular disease in a length of colon
FIG. 5. Case 2. 18.11.68. Cobblestone appearance in the pelvic colon with a few deep ulcers.
obviously affected by Crohn's disease, and vice versa, may be extremely difficult radiologically, it is usually possible. This allows an assessment to be made of the changes which occur in the colon over a period of time. The disappearance of diverticula with the development of Crohn's disease and their reappearance in remission is probably related to the tone of the bowel wall, which in turn is affected by the amount of induration and oedema and/or fibrosis present. It is generally accepted that diverticular disease is caused by increased intraluminal pressure arid certainly diverticula are more numerous radiologically when the colon is contracted than when it is relaxed. Inflammatory disease of the bowel radiologically appears usually to be associated with incomplete contraction and diminution or absence of stripping waves. This is seen not only in Crohn's disease, but also in ulcerative colitis, and in both these conditions the loss of function of the bowel may prevent the demonstration of the radiological postevacuation surface pattern. The combination of diverticula with ulcerative colitis is much rarer than with Crohn's disease, no doubt due to the fact that ulcerative colitis tends to occur in a younger agegroup than does diverticular disease. It cannot, of course, be concluded that the presence of inflammation in the bowel wall inhibits the formation of diverticula, but it does appear from these cases that inflammation due to Crohn's disease may result in the disappearance of diverticula, and that they may sometimes appear after subsidence of the inflammatory process. These points may be relevant to the interpretation of barium enema findings in these conditions. REFERENCES BERRIDGE, F. R., 1975. Crohn's disease; a review of its diverse radiological appearances. Journal of the Irish Colleges of Physicians and Surgeons, 5, 59-66. MARSHAK, R. H., JANOWITZ, H. D., and PRESENT, D. H., 1970.
Granulomatous colitis in association with diverticula. New England Journal of Medicine, 283,1080-1084. FIG. 6. Case 2. 9.1.69. The diverticula have re-appeared on the pelvic colon. The cobblestone mucosal pattern is no longer seen.
LOCKHART-MUMMERY, H. E., 1972. Crohn's disease of the
large bowel. British Journal of Surgery, 59, 823-826. SCHMIDT, G. T., LENNARD-JONES, J. E., MORSON, B. C ,
929
and YOUNG, A. C , 1968. Crohn's disease of the colon and its distinction from diverticulitis. Gut, 9, 7-16.
Effect of Crohn's disease on colonic diverticula By F. R. Berridge, M.B., F.R.C.P., F.R.C.R., and A. P. Dick, M.D., F.R.C.P. Departments of Radiology and Medical Gastroenterology, Addenbrooke's Hospital, Cambridge {Received January, 1976 and in revised form May, 1976) ABSTRACT
Fifteen cases in which the same part of the colon has been affected by both diverticular disease and Crohn's disease have been studied. When Crohn's disease affects an area of colon where diverticula are present, radiological examination may show a diminution in number or disappearance of the diverticula with progress of the Crohn's disease. With improvement in the Crohn's disease diverticula may appear.
Colonic diverticulosis is most often seen after the age of 50. Crohn's disease of the colon occurs not infrequently in the same age-group, so their occasional association is to be expected. Indeed, Crohn's disease affecting the distal colon has been observed to be particulary common in the elderly (LockhartMummery, 1972). The differentiation between Crohn's disease and diverticular disease, or the recognition that both are present, is clearly of vital importance in reaching decisions regarding treatment and may at times cause considerable difficulty (Schmidt et al, 1968; Marshak et al., 1970). The object of this study is to draw attention to a point of relevance to this problem. It has been observed that a length of colon found to be involved with diverticular disease on radiological examination may later show no diverticula, or a reduced number, when the same area is subsequently affected by Crohn's disease. Conversely, when Crohn's disease has improved, the appearance of diverticula has been noted. CLINICAL MATERIAL
Fifteen cases, in whom diverticular disease and Crohn's disease affected the same segment of colon, have been studied. There were four men and 11 women. Their ages ranged from 47 to 80 with a mean of 67. All except two were over 60. Apart from clinical and radiological evidence, the presence of Crohn's disease was established by a positive rectal biopsy with granulomata in seven. In two cases the rectal biopsy showed non-specific inflammatory changes, but the radiological picture was typical of Crohn's disease. Pathological examination of colectomy specimens in four further cases gave unequivocal evidence, while in another postmortem examination later confirmed granulomatous colitis. There was one patient who had been treated with azathioprine, where histological examination of the excised colon left the distinction between ulcerative colitis and Crohn's disease in doubt. However,
previous radiology had shown a long stricture with a communicating intramural sinus, rose-thorn ulcers and a recto-vaginal fistula. Of the four men, three had disease confined to the distal colon and rectum. In the fourth the distal colon was involved when the patient was first seen, but subsequently the disease spread to involve the whole colon and terminal ileum. Of the 11 women one had involvement of most of the colon and terminal ileum, two had a total colitis, four had left-sided colitis and four a distal colitis. Seven of the 11 women had anal lesions and two of the four men, but their presence was not correlated with the severity of the disease. The duration of the disease at the time the first barium enema was carried out was relatively brief, being six weeks or less in eight of the cases while the others had had symptoms for varying intervals up to 18 months.
RESULTS
Two of the patients had only one barium enema performed and are included for the sake of completeness. The remaining 13 cases had more than one examination and these can be divided into four groups: (A) No change in the diverticula when the Crohn's disease spread to involve the part of the bowel where the diverticula were situated—two cases. (B) The diverticula diminished in number when the Crohn's disease involved the segment of the bowel previously affected by diverticula—six cases. (C) The diverticula disappeared completely when the affected part of the bowel became involved with Crohn's disease—three cases. In one of these patients the diverticula subsequently reappeared when the Crohn's disease had become quiescent following a defunctioning ileostomy. (D) Following the subsidence of Crohn's disease diverticula appeared in an area of bowel previously affected by Crohn's disease—two cases. It is not known whether symptomless diverticulosis had been present in these two cases before the development of Crohn's disease.
926
NOVEMBER
1976
Effect of Crohn's disease on colonic diverticula CASE HISTORIES
Case! This 61-year-old housewife gave a six month history of worsening diarrhoea, latterly with blood in the stools, and two stone weight loss. Examination revealed a thin, pale, anxious woman. Anal skin tags were present. Haemoglobin 9 g.%. Sigmoidoscopy, under anaesthesia, showed reddening and irregular granularity of the rectal mucosa. Histology of rectal biopsies showed non-specific inflammatory changes.
Barium enema (27.2.59) showed narrowing and deep ulcers in the upper descending colon and the distal transverse colon. On the pelvic and iliac colon there were multiple diverticula (Fig. 1, a and b). Treatment with intramuscular corticotrophin gel was followed by considerable symptomatic improvement, but the patient returned five months later with a relapse, At this time sigmoidoscopy showed similar changes but histology on this occasion revealed the presence of granulomata. Cortico-steroids resulted in a remission but relapse occurred after three months. A barium enema at this time (18.3.60) showed extension of the disease proximally to the mid-transverse colon, where there were undermined ulcers, and distally to the iliac and pelvic colon where typical hyphen ulcers (Berridge, 1975) were seen. The descending colon was devoid of haustration. The affected part of the colon and rectum were narrowed and the post-rectal space increased. The diverticula, which had been present on the pelvic and iliac colon, had disappeared (Fig. 2, a and b). Progress was less satisfactory on further treatment with cortisone, and colectomy and ileostomy were performed four months later. The resected specimen showed Crohn's disease involving the caecum and the whole of the remainder of the colon, apart from the lowermost 10 cm of the ascending colon. No diverticula were present in the specimen. Case 2
A 49-year-old housewife presented with four months history of constipation with blood and slime in the stools. A diffusely reddened and oedematous mucosa was seen on sigmoidoscopy. Barium enema (5.1.65) showed diverticula on the distal transverse colon, descending colon and pelvic colon, but no other abnormality (Fig. 3). Treatment with sulphasalazine and courses of prednisolone retention enemata was followed by some improvement. Two years
FIG. 1. Case 1. 27.2.59. (A) Narrowing of the distal transverse colon. Diverticula on the descending and iliac parts of the colon. (B) Diverticula on the pelvic colon.
927
VOL.
49, No. 587 F. R. Berridge and A. P. Dick after the onset she developed an arthritis in several finger joints and a painful sacro-iliitis. At that time, barium enema (15.2.67) showed a few diverticula on the pelvic colon only and some narrowing of the rectum (Fig. 4). The joint symptoms subsided on treatment but shortly after this the picture changed with the development of diarrhoea, anal skin tags and an irregular cobblestone appearance in the inflamed rectum. Rectal biopsy showed non-specific inflammatory changes. Local steroid therapy produced some improvement but 18 months later she developed worsening diarrhoea and progressive anaemia, requiring transfusion. Barium enema (18.11.68) showed narrowing of the rectum and a cobblestone mucosal pattern
FIG. 3. Case 2. 5.1.65. Diverticula on the whole of the left side of the colon.
FIG. 2. Case 1. 18.3.60. (A) The diverticula on the descending and iliac colon no longer seen. Hyphen ulcers on the iliac colon. (B) Deep ulcers on the pelvic colon.
FIG. 4. Case 2. 13.2.67. Fewer diverticula now seen and only on the pelvic colon.
928
NOVEMBER 1976
Effect of Crohn's disease on colonic diverticula in the pelvic colon with a few deep ulcers. The diverticula in being removed. The wall of the ileum showed typical the pelvic colon had completely disappeared (Fig. 5). changes of Crohn's disease while throughout the colon there Shortly after this examination the patient became distended were scattered areas of mucosal ulceration and pseudoand laparotomy was performed. The pelvic colon was polyp formation, with extensive ulceration in the anal region. diffusely indurated and oedematous and the whole colon distended. An ileostomy was carried out. DISCUSSION Following this her general condition improved considerably. Barium enema (9.1.69) carried out on the defunctioned The association of diverticular disease and Crohn's colon showed a return of the diverticula in the pelvic colon disease in the same segment of colon is of considerand the cobblestone appearance of the mucosa could no longer be demonstrated (Fig. 6). Procto-colectomy was able interest. Although the establishment of the subsequently performed on 13.1.69, 8 cm of ileum also diagnosis of diverticular disease in a length of colon
FIG. 5. Case 2. 18.11.68. Cobblestone appearance in the pelvic colon with a few deep ulcers.
obviously affected by Crohn's disease, and vice versa, may be extremely difficult radiologically, it is usually possible. This allows an assessment to be made of the changes which occur in the colon over a period of time. The disappearance of diverticula with the development of Crohn's disease and their reappearance in remission is probably related to the tone of the bowel wall, which in turn is affected by the amount of induration and oedema and/or fibrosis present. It is generally accepted that diverticular disease is caused by increased intraluminal pressure arid certainly diverticula are more numerous radiologically when the colon is contracted than when it is relaxed. Inflammatory disease of the bowel radiologically appears usually to be associated with incomplete contraction and diminution or absence of stripping waves. This is seen not only in Crohn's disease, but also in ulcerative colitis, and in both these conditions the loss of function of the bowel may prevent the demonstration of the radiological postevacuation surface pattern. The combination of diverticula with ulcerative colitis is much rarer than with Crohn's disease, no doubt due to the fact that ulcerative colitis tends to occur in a younger agegroup than does diverticular disease. It cannot, of course, be concluded that the presence of inflammation in the bowel wall inhibits the formation of diverticula, but it does appear from these cases that inflammation due to Crohn's disease may result in the disappearance of diverticula, and that they may sometimes appear after subsidence of the inflammatory process. These points may be relevant to the interpretation of barium enema findings in these conditions. REFERENCES BERRIDGE, F. R., 1975. Crohn's disease; a review of its diverse radiological appearances. Journal of the Irish Colleges of Physicians and Surgeons, 5, 59-66. MARSHAK, R. H., JANOWITZ, H. D., and PRESENT, D. H., 1970.
Granulomatous colitis in association with diverticula. New England Journal of Medicine, 283,1080-1084. FIG. 6. Case 2. 9.1.69. The diverticula have re-appeared on the pelvic colon. The cobblestone mucosal pattern is no longer seen.
LOCKHART-MUMMERY, H. E., 1972. Crohn's disease of the
large bowel. British Journal of Surgery, 59, 823-826. SCHMIDT, G. T., LENNARD-JONES, J. E., MORSON, B. C ,
929
and YOUNG, A. C , 1968. Crohn's disease of the colon and its distinction from diverticulitis. Gut, 9, 7-16.
