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Print version ISSN 2237-9363
J. Coloproctol. (Rio J.) vol.32 no.2 Rio de Janeiro Apr./June 2012
Carlos Henrique Marques dos Santos
Assistant Professor, Universidade Federal de Mato Grosso do Sul (UFMS) - Campo Grande (MS), Brazil; Full Member of the Sociedade Brasileira de Coloproctologia
The endoscopic finding of ileal ulcers, alone or in small number, is not usual, but when it occurs in asymptomatic patients, an impasse may be generated regarding the action to be taken, since the medical literature is unclear as to how to proceed in this situation.
OBJECTIVE: Evaluate patients with ileal ulcers, single or in a small number, asymptomatic, and their follow-up.
METHODS: The author reports a series of asymptomatic cases (23 patients) of ulcers - single or in small number - found in colonoscopy exams performed for other reasons than typical clinical manifestations of Crohn's disease.
RESULTS: Most patients were not treated and remained asymptomatic during the follow-up period.
CONCLUSIONS: The patients remained asymptomatic and without treatment in most cases, and, considering the small number of cases and the short observation time, this study does not allow to conclude that this is the best practice in case of asymptomatic patients with ileal ulcer.
Keywords: Crohn's disease; ileal diseases; ileum; ulcer; pathology.
O achado endoscópico de úlceras ileais, isoladas ou em pequeno número, não é frequente, mas quando ocorre em pacientes assintomáticos pode gerar um impasse quanto à conduta a ser tomada, já que a literatura médica não é clara quanto a como se proceder nessa situação.
OBJETIVO: Avaliar pacientes que apresentaram úlceras ileais solitárias ou em pequena quantidade, assintomáticos e a evolução clínica dos mesmos.
MÉTODOS: O autor relata uma série de casos (23 pacientes) assintomáticos que apresentaram úlceras ileais únicas ou em pequeno número em colonoscopias realizadas por outros motivos que não manifestações clínicas típicas de doença de Crohn.
RESULTADOS: A maioria dos pacientes não foi tratada e permaneceu assintomática pelo período de acompanhamento.
CONCLUSÕES: Os pacientes permaneceram assintomáticos e sem tratamento em sua maioria, salientando-se o reduzido número de casos e o curto tempo de observação, de modo a não permitirem a este estudo concluir ser essa a conduta mais acertada frente à pacientes assintomáticos com achado de úlcera ileal.
Palavras-chave: doença de Crohn; doenças do íleo; íleo; úlcera; patologia.
One patient, at the return appointment, brought a colonoscopy exam showing one or more small ulcers in the terminal ileum, and such finding was a surprise, considering that the reasons for the exam did not include the suspicion of Crohn's disease (DC). Having discarded the other causes for these ulcers, but, without a convincing histopathological confirmation, how should we proceed? While the patient waits for a definition regarding the diagnosis and the treatment to be adopted, many questions are agitating the assistant physician's mind in this situation. Is it really CD? If the patient is asymptomatic, is it correct to start a treatment with possible adverse effects and for undetermined period? If the option is not treating the patient, wouldn't we be allowing the disease to develop and maybe appear in the future in more severe forms?
The situation described in this study has certainly occurred or will occur one day to physicians dedicated to the treatment of intestinal inflammatory diseases (IID). It is one of the various challenging situations related to IID that we should face in the daily practice and whose answers are vague in the current medical literature.
Evaluate patients with ileal ulcers, single or in a small number, asymptomatic, and their follow-up.
The author reports a case series of patients without CD symptoms, but presenting ileal ulcers at colonoscopy. The records of all patients (all adults) were retrospectively analyzed, regarding gender, age, symptoms and/or factors that required the colonoscopy exam, number of ulcers at colonoscopy, indication or non indication of treatment and follow-up. The study excluded patients that had recently used non-steroidal anti-inflammatory drugs and those with lesions, signs and/or symptoms suggestive of other specific diseases.
From February 9, 2004 to July 1st, 2011, the study analyzed 23 asymptomatic patients (11 male patients, 27 to 74 years old, mean age: 48 years old), whose colonoscopy exam presented ileal ulcers, not including here those patients that had recently used non-steroidal anti-inflammatory drugs and those with lesions suggestive of any specific diseases.
The patients' clinical conditions were not at first suggestive of CD; thus, the indications for colonoscopy were varied, and the endoscopic findings were not compatible with initial signs or symptoms. That was the main aspect that led to the description of this case series. The indications for colonoscopy included: hematochezia, pain and abdominal distension, as well as anal pain (Table 1).
Regarding the endoscopic findings, ileal ulcers were found, single or in small number, with biopsy performed for the histological analysis, which resulted in unspecific inflammatory process in all cases (Table 2). One patient presented diverticular disease in the sigmoid colon and one patient presented hemorrhoidal disease. No other concomitant finding was reported.
All 23 patients received explanations about the possible diagnosis, including the hypothesis of CD, and about the clinical treatment to be adopted. Only four of them decided to take the treatment. Two patients were prescribed mesalazine 3 g/day and two patients, azathioprine 150 mg/day. Mesalazine was prescribed in the first cases, of 2004 and 2006, when it was the standard treatment. For more recent cases, the option was azathioprine, according to current protocols.
Among the four treated patients, one (treated with mesalazine) did not come back and was not found for a new evaluation. The other three patients were reevaluated six months later. One of them (treated with mesalazine) started to present symptoms compatible with CD, the ileal ulcer remained and the treatment had to be altered. Today, this patient is asymptomatic, taking azathioprine. Another patient continues asymptomatic, but with ileal ulcer at colonoscopy. The treatment was interrupted and the patient has been under observation. And the other patient remained asymptomatic, but presented mild colitis at control colonoscopy, and for this reason, is still taking the treatment with azathioprine.
Among the 19 patients who did not decide to take the treatment, 8 have not returned and 11 were reevaluated, initially within 6 months on average, and these patients remained asymptomatic. One patient of this group was submitted to a surgery due to anal fistula and presented good progress. Control colonoscopy was performed and six of them still presented ileal ulcers, with the same initial characteristics. Thus, the option was to keep these 11 patients without treatment and under clinical observation (Table 3).
The literature has few articles addressing this situation of asymptomatic patients with ileal lesions compatible with CD. After discarding differential diagnoses, such as intestinal tuberculosis, ulcers related to the use of non-hormonal anti-inflammatory agents and opportunistic diseases, CD appeared as a very probable hypothesis. Histopathological findings of colonoscopic biopsy are not usually conclusive for CD diagnosis when analyzed individually. The collected material is often representative of the mucosa only, with unspecific inflammatory alterations that do not allow the pathologist to define the diagnosis1. That does not enable a fully satisfactory answer when we ask if single ileal ulcers in asymptomatic individuals are really manifestations of CD. If we consider that this is the probable diagnosis, how should be proceed?
Today, many specialists defend the idea of complete remission with the treatment of CD to prevent recurrence or the development of severe forms of the disease. In this sense, it sounds reasonable to prescribe the treatment to patients in the situation reported in this article. On the other hand, how to convince an asymptomatic patient to use drugs that may cause side effects and especially for undetermined period? The option in the cases of this study was to share with patients the decision on whether to take the treatment or not. As clearly demonstrated, most patients are not encouraged to take a treatment without a certain diagnosis, and especially without any symptom. Perhaps, this is the proper practice, as the follow-up of these patients showed that most of them did not require a treatment, but pointing out that it involved a small number of patients under observation and a short follow-up period.
The main study in the literature addressing this theme, and that somehow agrees with such decision is that conducted by Chang et al.2, which evaluated 93 asymptomatic individuals with ileal ulcers for almost 30 months. Among these, 60 had their condition resolved without any treatment and, although 31 remained with lesions at colonoscopy, only 1 progressed to typical symptoms of CD.
Olaison et al.3 observed that 22 among 30 patients submitted to ileocolectomy due to CD had ileal ulcers 3 months after the surgery, and among these, 10 presented early recurrence. The ulcers preceded the disease symptoms and the authors believe that this is a pre-clinical presentation of CD. Then, perhaps the ulcers found in asymptomatic individuals may precede more severe forms of the disease, but additional studies monitoring these individuals for longer periods are required to answer this question.
As observed in this study, most patients who presented asymptomatic CD remain with no alterations. However, when symptoms start to appear, they progress to CD4. Cosnes et al.5, in a recent study about the natural history of IIDs, report that many individuals present latent ileal CD for many years and may even not present it clinically. However, we should consider an important difference between individuals with inflammatory CD starting in the ileum and in the colon. Among those with inflammatory CD starting exclusively in the colon, 80% remain without alteration for 20 years, while those with the disease starting in the ileum tend to progress to more severe forms, with stenoses and fistulas, and, this way, less than 20% of the patients with ileal CD remain without alteration.
Therefore, many questions have not been answered regarding the real diagnosis of CD in endoscopic findings of ileal ulcers in asymptomatic individuals, which may be a latent form of the disease. The practice in this situation is still controversial, and additional well designed studies are required to help answer these questions.
Most patients remained asymptomatic and without treatment, but pointing out that the study involved a small number of cases and a short follow-up period, which did not allow to conclude if this is the best practice in case of asymptomatic patients with findings of ileal ulcer.
1. Zhou N, Chen W, Chen S, Xu C, Li Y. Inflammatory bowel disease unclassified. J Zhejiang Univ Sci B 2011;12(4):280-6. [ Links ]
2. Chang HS, Lee D, Kim JC, Song HK, Lee HJ, Chung EJ, et al. Isolated terminal ileal ulcerations in asymptomatic individuals: natural course and clinical significance. Gastrointest Endosc 2010;72(6):1226-32. [ Links ]
3. Olaison G, Smedh H, Sjödahl R. Natural course of Crohn's disease after ileocolic resection: endoscopically visualised ileal ulcers preceding symptoms. Gut 1992;33(3):331-5. [ Links ]
4. Courville EL, Siegel SA, Vay T, Wilcox AR, Suriawinata AA, Srivistava A. Isolated asymptomatic ileitis does not progress to overt Crohn disease on long-term follow-up despite features of chronicity in ileal biopsies. Am J Surg Pathol 2009;33(9):1341-7. [ Links ]
5. Cosnes J, Gower-Rousseau C, Seksik P, Cortot A. Epidemiology and natural history of inflammatory bowel diseases. Gastroenterology 2011;140(6):1785-94. [ Links ]
Carlos Henrique Marques dos Santos
Rua XV de Novembro, 1.859 - Vila Esportiva
CEP: 79030-200 - Campo Grande (MS), Brazil
Submitted on: 01/09/2012
Accepted on: 01/13/2012
Financing source: none.
Conflict of interest: nothing to declare.
Study carried out at the Department of Surgical Practice, Faculdade de Medicina Professor Dr. Hélio Mandetta, Universidade Federal de Mato Grosso do Sul (UFMS) - Campo Grande (MS), Brazil.