Gastroenterology

Gastroenterology

Volume 114, Issue 2, February 1998, Pages 262-267
Gastroenterology

Alimentary Tract
Early lesions of recurrent Crohn's disease caused by infusion of intestinal contents in excluded ileum

https://doi.org/10.1016/S0016-5085(98)70476-7Get rights and content

Abstract

Background & Aims: Postoperative recurrence of Crohn's disease may be triggered by agents in the fecal stream. The aim of this study was to examine intestinal mucosal inflammation induced by contact with intestinal fluids in surgically excluded ileum. Methods: The effects of infusion of intestinal luminal contents into excluded ileum in 3 patients with Crohn's disease who had undergone a curative ileocolonic resection with ileocolonic anastomosis and temporary protective proximal loop ileostomy were studied by histopathology and electron microscopy. Results: Contact with intestinal fluids for 8 days induced focal infiltration of mononuclear cells, eosinophils, and polymorphonuclear cells in the lamina propria, small vessels, and epithelium in the excluded neoterminal ileum that was previously normal. Epithelial HLA-DR expression increased, and mononuclear cells expressed the KP-1 antigen associated with activation. Marked up-regulation of RFD-7, RFD-9, intercellular adhesion molecule 1, and lymphocyte function–associated antigen 1 was observed after infusion, reflecting epithelioid transformation and transendothelial lymphocyte recruitment. At the ultrastructural level, dilatation of the endoplasmic reticulum and Golgi apparatus occurred in epithelial cells, where also basally located transport vesicles were identified. Conclusions: Intestinal contents trigger postoperative recurrence of Crohn's disease in the terminal ileum proximal to the ileocolonic anastomosis in the first days after surgery.

GASTROENTEROLOGY 1998;114:262-267

Section snippets

Materials and methods

Three patients, 29, 38, and 51 years old, underwent a resection of the diseased terminal ileum with ileocolonic anastomosis and a temporary diverting “loop-ileostomy” constructed proximally to the anastomosis.4 The indication for diversion of the fecal stream was perforation and severe anal disease in 1 patient, ileal disease with fistulization to the rectosigmoid colon and sacral bone in the second patient, and perforation of a previously constructed ileocolonic anastomosis in the third

Results

The endoscopic appearance of the neoterminal ileum was normal before as well as after challenge with ileal fluid, although minor sequelae of biopsy removal were observed at day 8. All ileal biopsy specimens from the distal loop of the neoterminal ileum were entirely normal before reinfusion in the 3 patients with Crohn's disease. None of them experienced any symptoms during this week. After reinfusion, a moderate to severe increase of mononuclear cells and eosinophils in the lamina propria and

Discussion

Inflammatory cells in Crohn's disease enter the mucosal compartment via transendothelial migration promoted by adhesion molecules. Monocytes, T cells, and neutrophils all contribute to the formation of an inflammatory infiltrate. The majority of mononuclear cells infiltrating the inflamed mucosa has been recruited recently from the circulation.12 In the present study on the effects of infusion of intestinal contents into the excluded ileum and ileocolonic anastomosis, we show that inflammatory

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    Address requests for reprints to: Geert R. D'Haens, M.D., Ph.D., Department of Internal Medicine, University Hospital Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium. Fax: (32) 16-34-4299.

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