Surgical treatment of acute manifestations of Crohn's ... - Europe PMC

JOURNAL OF THE ROYAL SOCIETY OF MEDICINE

Volume 90

February 1 997

Surgical treatment of acute manifestations of Crohn's disease during pregnancy J Hill ChM FRCS1

A Clark MB2

NA Scott

MD

FRCS2

J R Soc Med 1997;90:64-66

SUMMARY When requiring surgery, acute exacerbations of Crohn's disease in pregnancy have been reported to carry high maternal and fetal mortality. We report six cases. The women presented at 30, 28, 12, 11, 31 and 25 weeks' gestation and all proved to have intraperitoneal sepsis. In three, the acute symptoms were the first indication of Crohn's disease. All the women recovered and five had healthy babies; the other had a miscarriage when a colonic anastomosis dehisced. In pregnant women with Crohn's disease, the indications for surgery are the same as in non-pregnant patients. For acute manifestations we recommend removal of the source of the sepsis and exteriorization of the bowel ends.

INTRODUCTION In women with Crohn's disease, fertility is subnormal. Dyspareunia, involvement of the fallopian tubes in the

disease process, general ill health and medical advice against pregnancy have all been implicatedl2. Once pregnancy has been achieved, healthy offspring can be expected. Abnormal birth weight, stillbirth, spontaneous abortion and congenital abnormalities are no more common than in the population without inflammatory bowel disease4. Patients whose Crohn's disease is in remission at the time of conception usually remain symptom-free during pregnancy, with relapse rates similar to *those documented in the National Co-operative Crohn's Disease Study5, and their pregnancy outcomes are similar to those in the general population. Of women who have active Crohn's disease at the beginning of pregnancy 60-70% continue to have active disease during the pregnancy despite medical therapy3'6. In this group there is a suggestion of a decreased rate of live births3. There is no evidence that patients developing symptoms for the first time during pregnancy experience unusually severe disease. During the puerperium the risk of relapse seems no higher than usual. Severe exacerbations of Crohn's disease in pregnancy are rare. Even less common are acute manifestations that require surgery3'7-9, but in reported cases maternal and fetal mortality rates have been high9. We describe the cases of six patients who developed acute intraperitoneal sepsis secondary to Crohn's disease during pregnancy. 'Department of General and Colorectal Surgery, Manchester Royal Infirmary, Manchester Ml 3 9WL; 2University Department of Surgery, Clinical Sciences

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Building, Hope Hospital, Salford M6 8HT, England Correspondence to: Mr NA Scott

CASE HISTORIES

Case I A woman aged 28, previously healthy, developed colicky abdominal pain and bloody diarrhoea when 30 weeks pregnant. Colonoscopy revealed patchy colitis and she was started on oral steroids. At 36 weeks the membranes ruptured spontaneously and she had a normal delivery. Within 48 h she complained of increasing abdominal pain and on examination she had a diffuse peritonitis caused by a ruptured abscess involving the liver, secondary to ileocaecal Crohn's disease. An ileocaecectomy was performed with an end ileostomy and mucus fistula. Postoperatively a pelvic abscess developed and this was drained per vaginam. Because of ongoing intraperitoneal sepsis, a further laparotomy and laparostomy were performed. Her eventual recovery was further complicated by cardiomyopathy secondary to selenium deficiency. Case 2 A woman of 22 with no history of Crohn's disease developed anorexia, diarrhoea and colicky abdominal pain with passage of mucus per rectum when 28 weeks pregnant. A therapeutic trial of prednisolone 20 mg daily produced some improvement. When 36 weeks pregnant she reported increasing abdominal pain with left iliac fossa tenderness and rebound. Shortly after admission her membranes ruptured spontaneously and a healthy child was delivered. Over the next 24 h peritonitis developed. Laparotomy revealed terminal ileal Crohn's disease with a free perforation and purulent peritonitis. The diseased bowel was resected and ileocolonic anastomosis was performed. Postoperatively a


pelvic abscess developed and was drained via the rectum. Thereafter she made a good recovery. Case 3 A woman of 36 with no history of Crohn's disease presented when 12 weeks pregnant with severe perianal ulceration. Depot-methylprednisolone was injected under anaesthesia. At 16 weeks she complained of severe constant lower abdominal pain and had signs of peritonitis. On laparotomy there was active colonic Crohn's with an abscess related to sigmoid colon. This was resected and a primary end-end anastomosis was performed. Postoperatively the anastomosis dehisced and she had a miscarriage. At further laparotomy a Hartman procedure was performed. Her subsequent recovery was uncomplicated. Case 4 A woman aged 24 with recurrent perianal abscesses presented 11 weeks pregnant with an enterovesical fistula. An ultrasound examination demonstrated thickened bowel and a mass involving bowel in the pelvis. At laparotomy a pelvic abscess was found and active terminal ileal Crohn's disease was fistulating through the dome of the bladder. An ileocaecectomy was performed with an end ileostomy and mucus fistula. The subsequent pregnancy was uncomplicated and a healthy infant was delivered at term. The end ileostomy and mucus fistula were successfully reanastomosed 3 months after delivery.

Case 5 A woman of 21 with a 5-year history of Crohn's disease, including an ileocaecectomy for terminal ileal disease 3 years earlier, presented 31 weeks pregnant with increasing constant abdominal pain with colicky exacerbations and vomiting. On examination she was tender with rebound and guarding to the right of the uterus. Over the next 24 h the signs did not improve and a laparotomy with lower segment caesarean section was performed; a live girl was delivered. A perforated abscess, adjacent to a segment of recurrent perforating Crohn's disease at the old ileocolonic anastomosis, was present with a purulent peritonitis. The anastomosis was resected, an end ileostomy was made and a mucus fistula was brought out. Mother and child did well. Intestinal continuity was re-established subsequently. Case 6 A woman of 27 with 7-year history of Crohn's disease who required azathioprine and steroids to control her disease presented 25 weeks pregnant with diffuse abdominal pain and peritonitis. On laparotomy she had a purulent peritonitis and a diffusely abnormal left colon although no perforation

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was detected. The peritoneal cavity was lavaged and drains were placed to the left side of the colon. At 36 weeks she had an elective caesarean section and an end ileostomy was formed to defunction the affected colon. A chronic left iliac fossa abscess developed subsequently and she went on to have a total colectomy. DISCUSSION

In three of the six patients symptoms of Crohn's disease developed for the first time during pregnancy. Such patients present a diagnostic challenge. The symptoms typical of Crohn's disease-colicky abdominal pain, distension, nausea and vomiting-are all frequently experienced during pregnancy. Altered bowel habit is also common in both conditions, though late pregnancy is usually associated with constipation rather than the diarrhoea characteristic of inflammatory bowel disease. Standard radiological investigations for Crohn's disease such as small and large bowel enemas and labelled white cell scans are contraindicated because of the radiation exposure to the fetus. Rigid and flexible sigmoidoscopy can be performed safely at any time during pregnancy7. Ultrasound scanning may identify thickening of the wall of the terminal ileum or the presence of an intra-abdominal abscess. Magnetic resonance imaging is a safe noninvasive investigation in pregnancy and has been useful in establishing the diagnosis of Crohn's disease10. The other three patients described in this series had known Crohn's disease. The rarity of acute surgical problems in pregnancy may lead to delays in management11. It is therefore advisable that both an obstetrician and a surgeon are involved in the patient's management12. When a woman with a history of Crohn's disease presents with peritonism the possibility of an acute manifestation of the disease must be considered. In such circumstances surgery should not be long delayed-a lesson that has been well learned in acute appendicitis. When the appendix is nonperforated, the maternal and fetal mortality is nil; when the appendix has perforated, maternal mortality may be as high as 17% and fetal mortality as high as 43%13. Five of the six patients described in this series had a free perforation of Crohn's disease. The maternal mortality was nil and one fetus was lost. Two possible mechanisms may account for free perforation of Crohn's disease during pregnancy. Either an abscess adjacent to the Crohn's segment is ruptured by the mechanical stress of labour or there is failure of the intra-abdominal viscera to 'wall-off inflamed segments. In the latter case, the large uterus may prevent the omentum and other abdominal contents from adequately localizing the inflammation14. Intra-abdominal surgery performed during the first trimester is associated with an increased risk of miscarriage.

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For planned procedures in the second trimester the risk is lower. In the third trimester laparotomy may be complicated by premature delivery and technical difficulties. 16. However, it is the surgical condition, not the operation, that determines maternal and fetal risk15. Indications for surgical therapy in both Crohn's disease and ulcerative colitis during pregnancy are the same as in non-pregnant patients. When acute manifestations of Crohn's disease are present we recommend removal of the source of sepsis and exteriorization of the bowel ends. Pelvic sepsis persisted in two of four patients despite exteriorization and in both the patients whose bowel was not exteriorized. Active intraperitoneal sepsis increases the risk of anastomotic leakage and miscarriage. Intestinal stomas seldom cause difficulty; if, after delivery, the residual bowel is healthy, reanastomosis can be performed.

4 Khosla R. Willoughby CP, Jewell DP. Crohn's disease and pregnancy. Gut 1984;25:52-6 5 Summers RW, Sqitz DM, Session DT, et a]. National Cooperative Crohn's Disease study: results of drug treatment. Gastroenterology 1979;77:847-69 6 Mogadam M, Korelitz BI, Ahmed SW, et al. The course of inflammatory bowel disease during pregnancy and post partum. Am J Gastroenterol 1981;75:265-9 7 Korelitz BI. Inflammatory bowel disease in pregnancy. Gastroenterol Clin N Am 1992;21:827-34 8 Crohn BB, Yarnis H. Korelitz BI. Regional ileitis complicating pregnancy. Gastroenterology 1956;31:615-28 9 Blair JSG, Allen N. Crohn's disease presenting acutely during pregnancy. J Obstet Gynaecol Br Commonw 1962;69:648-51 10 Shoenut JP, Semelka RC, Silverman R, Yaffe CS, Micflikier AB. MRI in the diagnosis of Crohn's disease in two pregnant women. J Clin Gastroenterol 1993;17:244-7 11 Devore GR. Acute abdominal pain in the pregnant patient due to pancreatitis, acute appendicitis, cholecystitis or peptic ulcer disease. Clin Perinatol 1980;7:349-67 12 Smolniec J, James D. General surgical problems in pregnancy. BrJ Surg 1990;77: 1203-4 13 Horowitz MD, Gomez GA, Santiesteban R, Burkett G. Acute appendicitis during pregnancy. Arch Surg 1985;120:1362-7 14 Babaknia A, Hossein P, Woodruff JD. Appendicitis during pregnancy. Obstet Gynecol 1977;50:40-4 15 Kammerer WS. Non-obstetric surgery during pregnancy. Obstet Gynecol 1977;50:40-4 16 Dixon NP, Green J, Rogers A, Rubin L. Fetal loss after cholecystectomy during pregnancy. Can Med AssocJ 1983;88:576-7 17 Willoughby CP. Inflammatory bowel disease and pregnancy. In: Allan RN, Keighley MRH, Alexander-Williams J, Hawkins C, eds. Inflammatory Bowel Diseases. Edinburgh: Churchill Livingstone, 1990:552-5

Acknowledgments We thank Professor Sir Miles Irving, Professor LE Hughes and Mr J Hobbiss for allowing us to report their patients. REFERENCES I Baiocco PH, Korelitz BI. The influence of inflammatory bowel disease and its treatment on pregnancy and fetal outcome. J Clin Gastroenterol 1984;6:21 1-16 2 Mayberry JF, Weterman IT. European survey of fertility in women with Crohn's disease: a case controlled study by a European collaborative group. Gut 1986;27:821-5 3 Hana IM. Inflammatory bowel disease in the pregnant woman. Clin Perinatol 1985;12:682-99

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