Br. J. Surg. Vol. 61 (1974) 291-292

Life-t hreateni ng haemorrhage in Croh n’s disease H . N . 0. SUNKWA-MILLS*

SUMMARY A n unusual presentation of Crohn’s disease is reported. Massive rectal haernorrhage threatening the life of the patient resulted in emergency right hemicolectorny. No further bleeding has since occurred.

PERHAPS the first mention of what is now known as Crohn’s disease or regional enteritis was that of William Saunders in a paper read at the Royal College of Physicians in 1806. It was not until 1932 that Crohn et al. published their description of this condition. The specific histological appearances were detailed by Hadfield in 1939.

Crohn’s disease is not a rare condition and its symptomatology is now well established. In spite of this, isolated cases of unusual presentation, i.e. massive rectal haemorrhage, have been encountered. Massive rectal haemorrhage alone can present the attending clinician with many problems. There are only a few cases of massive rectal haemorrhage due to Crohn’s disease reported in the literature (Fallis, 1941, I case; Norcross and Cattell, 1944, 1 case; Freedman, 1952, 1 case; Brown, 1957, 1 case; Goldberg and Frable, 1963, 2 cases; Sparberg and Kirsner, 1966, 1 case).

Case report On 19 November, 1971, a 15-year-old white male was admitted as an emergency to the Queen Elizabeth 11 Hospital. He had previously been quite well apart from an 18-month history of intermittent ‘cramp-like’ abdominal pains. Three days prior to admission he had passed onedark loose motion, the following day he had passed three further dark loose motions and on the day prior to admission he had passed several loose motions, all dark, but on these occasions there had been frank red blood mixed with the stools. There was nothing significant in the patient’s past medical history.

Examination revealed a well-nourished young man weighing 95 kg. He looked pale, but was not in obvious pain. His tongue was dry and he was afebrile. His pulse rate was IlOjminute and bounding and his blood pressue was ISOjSO. There was some vague tenderness in the epigastrium. No mass was palpated.

Investigations revealed the following: haemoglobin 6.8 gjl00 ml, packed cell volume 22 per cent, mean corpuscular haemo- globin concentration 31 per cent and platelets adequate. A blood film showed anisocytosis and polychromasia. The electrolytes were within normal limits, the blood urea was 33 mg/100 ml while liver function tests, serum enzymes, prothrombin time and clotting time were all normal. Chest and plain abdominal X-rays showed no abnormality.

Provisional diagnoses of haemorrhage from Meckel’s diverticulum and Crohn’s disease were made.

Within 24 hours 9 units of whole blood were transfused. Despite this, the patient continued to have massive rectal haemorrhage. Although his pulse rate hovered around 110- 120/minute and his blood pressure was 130/80, it was decided to proceed with laparotomy.

Crohn’s disease of the last 30 cm of the terminal ileum with two 4-cni skip lesions above this were found at laparotomy.

Right hemicolectomy was performed. Postoperatively 1 unit of blood was transfused.

After operation the haemoglobin was 12.8 g/lOO ml, packed cell volume 45 per cent, and the electrolytes and blood urea were normal.

Progress was uneventful and the patient was discharged home on the fourteenth day. Since then he has been reviewed twice. He has remained well and there has been no further haemorrhage and ‘abdominal cramps’.

The report of the pathology was as follows. Macroscopically, the specimen consists of terminal ileum, 30cm in length, together with caecum and ascending colon, measuring 22.0 cm in length. The terminal ileum from the region of the ileocaecal valve shows marked thickening of the wall with narrowing of the lumen and ulceration of the mucosa for a distance of 14 cm, where there is a skip area of 4 cm in length and another small constricted area measuring 1.0 cm in length. The remainder of the terminal ileum appears normal; 2.5 cm from the ileocaecal valve there is an ulcer measuring 3.0 cm in diameter, with the appearance of the structure in the base suggesting a small arteriole. Lymph nodes in the mesentery are markedly enlarged.

Microscopically, sections show normal appearances a t the proximal line of resection and an essentially normal appear- ance at the skip area. Sections of the proximal and distal lesions in the ileum show surface acute inflammatory exudate with areas of mucosal ulceration, marked fibrosis and oedema of the submucosa; lymphoid hyperplasia and a moderate chronic non- specific inflammatory cellular infiltrate are present in the muscle layers with a similar considerably more dense infiltrate in the serosa. Occasional ill-defined epithelioid foci are present in the submucosa. Sections of the lymph nodes show large numbers of well-defined epithelioid foci with occasional Langhans’s giant cells. The appearances are those of Crohn’s disease.

Comment Although the symptomatology of regional enteritis is well established, occasionally massive rectal haemor- rhage which may threaten the life of the patient is the first symptom. Most textbooks fail to mention this presentation. The aim of this paper is to stress the importance of this symptomatology and to remind clinicians to consider regional enteritis in the differ- ential diagnosis of massive rectal haemorrhage.

Acknowledgement I wish to thank Mr Gordon F. Cassie, Consultant Surgeon, for kindly allowing me to report on one of his patients and for his help in preparing this article.

References BROWN P. w. (1957) Massive recurring bleeding in

regional enteritis. Minnesota Med. December 1957, 847-848.

CROHN B. B., GINZBURG L. and OPPENHEIMER G. D. (1932) Regional ileitis: a pathological and clinical entity. JAMA 99, 1323-1329.

* Queen Elizabeth 11 Hospital, Welwyn Garden City, Herts.

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FALLIS L. s. (1941) Massive intestinal hemorrhage in regional enteritis; report of a case. Am. J. Surg.

FREEDMAN P. (1952) Regional ileitis presenting as recurrent intestinal haemorrhage. Br. Med. J. 2, 268.

GOLDBERG s. L. and FRABLE M. A. (1963) Massive intestinal hemorrhage in regional enteritis. Surgery 53, 612-614.

HADFIELD G. (1939) The primary histological lesion of regional ileitis. Lancet 2, 773-775.

53, 512-513.

NORCROSS J. w. and CATTELL R. B. (1944) Symposium on gastro-intestinal surgery; management of gastro-intestinal haemorrhage, report of case. Surg. Clin. North Am. 24, 675-678.

SAUTER, K. E. (1966) Massive gastrointestinal hemor- rhage due to regional enteritis. Am. J. Surg. 112, 91-93.

SPARBERG M. and KIRSNER J. (1966) Recurrent hemor- rhage in regional enteritis. Report of 3 cases. Am. J , Dig. Dis. 2, 652-651.

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