Crohn's disease · Crohn's disease ofthe colon andits distinction fromdiverticulitis G. T. SCHMIDT, J. E. LENNARD-JONES, B. C. MORSON, AND A. C. YOUNG FromSt. Mark'sHospital, London

Gut, 1968, 9, 7-16

Crohn's disease of the colon and itsdistinction from diverticulitis

G. T. SCHMIDT, J. E. LENNARD-JONES, B. C. MORSON, ANDA. C. YOUNG

From St. Mark's Hospital, London

Crohn's disease may affect segments of the colon(Brooke, 1959; Lindner, Marshak, Wolf, andJanowitz, 1963; Lockhart-Mummery and Morson,1960, 1964) where diverticula are a common findingin the middle-aged and elderly (Dearlove, 1954;Pemberton, Black, and Maino, 1947). It wouldthus be surprising if Crohn's disease did not some-times occur in the region of colonic diverticula andthe object of this paper is to describe 26 suchpatients.Some of these patients presented little diagnostic

difficulty. Others, with colonic diverticula, presentedas 'diverticulitis' but the inflammation of the colonwas subsequently shown to be due to Crohn's disease.Patients have also been seen who were diagnosedas diverticulitis but were later found to have Crohn'sdisease without any diverticula being present.

NOMENCLATURE

In this paper the term 'diverticulosis' is used todescribe the presence of colonic diverticula asshown radiologically and/or pathologically. Theterm 'diverticular disease' is used to describe thatcondition in which there is an abnormality of muscleof the sigmoid colon with or without diverticula(Morson, 1963; Williams, 1963; Arfwidsson, 1964).'Diverticulitis' is used here only when inflammationhas occurred as a complication of diverticulosis.The use of the expression 'Crohn's disease' has beendescribed in previous papers (Lockhart-Mummeryand Morson, 1960, 1964). It is synonymous withthe terms 'regional enteritis' (Crohn and Yarnis,1958) and 'granulomatous colitis' (Lindner et al.,1963).

CLINICAL MATERIAL

The records of 137 patients with Crohn's disease ofthe colon have been reviewed and 26 were found inwhich both diverticula and Crohn's disease werepresent. The cases have been analysed and dividedinto two groups.

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GROUP I: DIAGNOSIS MADE ON A RESECTED SPECIMENFourteen patients have been seen with Crohn'sdisease and diverticula of the sigmoid colon in whomthe diagnosis was established by pathologicalexamination of a resected specimen. Nine of these14 patients were diagnosed clinically as diverti-culitis, four as Crohn's disease, and one as ulcera-tive colitis. Crohn's disease was diagnosed in thepresence of colonic diverticula in 10 of the 14specimens when first examined but in the otherfour only after review of the pathology followingthe development of characteristic postoperativecomplications such as anal or entero cutaneousfistulae.

Case 1 A 69-year-old man complained of inter-mittent rectal bleeding for four years, left-sided lowerabdominal pain, and recent diarrhoea. He was foundto have an unhealed anal fistula which had been presentfor two years: sigmoidoscopy was normal to 15 cm.Radiographs showed colonic diverticula and a diagnosisof diverticulitis was made.At laparotomy a large mass, presumed to be diverti-

culitis, was found in the sigmoid region and diverticulaextending to the proximal transverse colon were alsonoted. The mass was resected and on pathologicalexamination was thought to show diverticulitis.

Within 12 months the patient returned with a dis-charging sinus in the left iliac fossa, continued rectalbleeding, and a chronic anal fissure. At laparotomy anentero-colic fistula was closed, an abscess around theanastomosis was drained, and a proximal colostomyperformed. Following this he made an uneventful re-covery but died from an unrelated cause some monthslater.

In view of the breakdown of the anastomosis anddevelopment of a fistula after the first operation thehistology of the resected colon (Fig. 1) was reviewed.Mucosal ulceration (Fig. 2) with transmural inflamma-tion and fissuring (Fig. 3) and foci of epithelioid andgiant cells were found and an amended diagnosis ofCrohn's disease of the sigmoid colon associated withdiverticula was made. Examination of a biopsy specimenfrom the anal fistula taken 15 months before his referralto St. Mark's also revealed foci of sarcoid tissue con-sistent with a diagnosis of Crohn's disease.

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FIG. 2.

FIG. 1. Case 1: surgical specimen of descending andsigmoid colon. There is muscular thickening and corruga-tion of the bowel wall with mucosal redundancy in thesigmoid colon and extensive diverticulosis throughout thespecimen. In the sigmoid there is also fibrous thickeningof the bowel wall with stenosis of the lumen.

FiIG. 2. Case 1: close-up of descending colon from Fig. 1showing patchy irregular ulceration around the orificesof diverticula.

FIG. 3. Case 1: close-up ofsigmoidpart ofFig. 1 showingfibromuscular thickening of the bowel wall extending intothe pericolic fat. The mucosa is granular and nodular andfissuring with intramural abscess formation is present.

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Crohn's disease of the colon and its distinction from diverticulitis

Case 2 A 55-year-old man was referred to St. Mark'sHospital suffering from an anal fistula which had beencausing pain and discharge for two months. Bleedingwith defaecation had occurred at the onset of his symp-toms but he did not complain of any change of bowelhabit or of any significant abdominal pain. Bariumenema (Fig. 4) showed the asymmetrical fold pattern andnarrowing of diverticular disease with a few diverticulaand some spiky folds thought to be a localized peri-diverticular abscess. The anal fistula was laid open andsubsequently healed satisfactorily.

Five months later he returned complaining of ab-dominal pain, of alternating constipation and diarrhoea,and of loss of 1 stone in weight over six months. Sig-moidoscopy was normal and the anal fistula appeared tohave healed completely.The pain persisted and was attributed to diverticulitis.

At operation a segment of inflamed sigmoid colon whichwas adherent to the adjacent bowel and ureter was

resected. The operative diagnosis was diverticulitis buthistological examination of the specimen showed Crohn'sdisease and diverticulosis. He made an uneventful re-covery and barium examination of the small bowelrevealed no changes of Crohn's disease. Review of theoriginal enema films suggested that the spiky patternseen was due to Crohn's disease rather than a peri-diverticular absoess.

Case 3 A woman of 72 years was admitted complain-ing of diarrhoea, anorexia, and loss of weight over aperiod of 18 months. On examination a mass was feltin the left iliac fossa, and inspection of the anus revealedlarge oedematous skin tags. Sigmoidoscopy showed pus,blood, and mucus in the rectum with hyperaemia andoedema of the mucosa. Barium enema (Fig. 5) showednarrowing of the lumen of the descending and sigmoidcolon associated with multiple diverticula and a diagnosisof diverticulitis with paracolic abscess was made.At operation most of the colon was found to be in-

FIG. 4. FIG. D.

FIG. 4. Case 2: double contrast barium enema. The sigmoid region shows the characteristically asymmetricalfoldpanternand several diverticula ofdiverticular disease. But on the medial aspect oftheproximal curve (opposite the midpoint ofthesacral promontory) is a deep spike accompanied by a shorter one. Such spiking might be due to non-specific diverticulitis,but in this case it is the spiking ofCrohn's disease.FIG. 5. Case 3: the sigmoid colon has an abnormal asymmetrical fold pattern and a few diverticula. The adjacent des-cending colon and the splenicflexure show an even more irregularfoldpattern with well-markedfissuring, best seen in thesplenic flexure.

This is a good example of the signs ofdiverticular disease being exceededpartly in extent, since grossfold changes aweusually confined to the sigmoid, andpartly in degree, since even in the sigmoid the irregular irregularity of the lumen andthe fissuring would suggest Crohn's disease.

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G. T. Schmidt, J. E. Lennard-Jones, B. C. Morson, and A. C. Young

volved by an inflammatory process causing markedthickening of the bowel wall with oedema of the mesen-tery. Subtotal colectomy was performed. Pathologicalexamination of the resected specimen showed diffuseCrohn's disease of the colon with muscular hypertrophyand diverticulosis of the sigmoid (Figs. 6 and 7).The patient has been seen at the follow-up clinic for

five years and has had no further symptoms.Case 4 A man of 61, a lifelong sufferer from con-

stipation, complained of anal discharge since the ruptureof an abscess six months previously. A posterior analfistula was present, and, on sigmoidoscopy to 18 cm.,blood was observed coming from above. A barium enema

suggested severe diverticulitis of the sigmoid colon anda possible growth in the caecum. At laparotomy, theonly abnormality found was gross thickening of thesigmoid colon attributed to diverticulitis. Resection ofthe diseased bowel with anastomosis was performed.Subsequently the anal fistula was laid open and healednormally. Examination of the resected specimen (Fig. 8)showed a few diverticula and, separate from the diverti-cula, chronic intramural inflammation, with hyperplasiaof lymphoid tissue and many non-caseating giant cellsystems. One lymph gland contained sarcoid foci. Thetrack from the anal fistula also contained giant cellsystems. The patient is well five years after operation.

FIG. 7.

FIG. 6. Case 3: surgical specimen of left colon showingdiffuse cobblestone appearance of the mucous membrane.In addition the sigmoid shows much muscular thickeningand corrugation of the bowel wall typical of diverticulardisease.

FIG. 7. Case 3: close up ofsigmoid colon from Figure 6.Diverticula can be distinguished from the knife-likefissures of Crohn's disease passing through the bowel wall.Some diverticula show ulceration of their mucosal liningand there is extensive transmural inflammation extendinginto the pericolik fat with fibrosis.

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FIG. 8. Case 4: surgical specimen of sigmoid colonshowing muscular thickening and corrugation of the bowelwall with mucosal redundancy and diverticulosis. Themucous membrane is thick and granular and in the centralpart of the specimen there is intramural and extramuralfibrosis. Microscopic examination reveals features ofCrohn's disease as well as diverticular disease.

GROUP II: DIAGNOSIS MADE ON A BIOPSY SPECIMENIn 12 patients the diagnosis of Crohn's disease wasestablished by rectal biopsy or histological examina-tion of tissue from anal lesions. In this groupdiverticula of the sigmoid were demonstratedradiologically but no resected specimen was avail-able for examination. The initial clinical diagnosiswas Crohn's disease in seven patients, diverti-culitis in two, ulcerative colitis in two, and tuber-culous proctitis in one. Crohn's disease, in additionto the diverticula, wa3 suggested radiologicallyin nine patients. As in group I, the majority of thesepatients presented with diarrhoea (9), rectal bleeding(10), anal lesions (11), and an abnormal sigmoid-oscopic appearance (12).Case 5 is discussed in some detail as being a

typical example of this second group.

Case S A male of 63 complained of anorectal dis-comfort for five months, and of passing frequent stoolsmixed with blood and mucus. On examination, severalchronic anal fissures and a fistula were present andsigmoidoscopy revealed a granular inflamed mucosawith some blood and mucopurulent exudate in the lowerrectum. Many sigmoid diverticula were seen radiologically(Fig. 9) as well as some granularity of the rectum withwidening of the recto-sacral space. A clinical diagnosisof Crohn's disease was supported by a rectal biopsywhich showed a chronic granulomatous infiltration withmany sarcoid foci. After the fistula had been laid openthe patient developed an exacerbation of symptoms withfever, abdominal pain, and distension. As it was difficultto be sure if these symptoms were due to the Crohn'sdisease or an attack of diverticulitis, he was treated atfirst with antibiotics but without effect. An immediateresponse followed the administration of prednisone(40g daily), the dose of which was gradually reduceduntil the drug was stopped after nine weeks. He is wellsix months later, passing two or three formed stools daily,the anal lesions having healed five weeks after commenc-ing treatment.

This case illustrates that there may be very realdifficulty in deciding whether symptoms are due todiverticulitis or Crohn's disease. In this patient anti-biotics were ineffective but corticosteroid therapywas successful.

GROUP III: CROHN'S DISEASE SIMULATING DIVERTI-CULITIS A further two patients were diagnosed asdiverticulitis but pathological examination of theresected specimens showed Crohn's disease, pre-dominantly of the sigmoid colon, without diverti-cula.

Case 6 A 59-year-old woman was transferred to thishospital four months after the onset of anorexia, weightloss of 3 stone, constipation, and the passage of bloodand mucus on defaecation. At another hospital a hard,

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FIG. 9. Case 5: double contrast barium enema. Theproximal sigmoid has an asymmetrical fold pattern (of amoderately regular type) and diverticula. The distal sig-moid has a diminishedfold pattern; the rectum is irregularin outline and the original film showed fine granularity ofthe rectal mucosa.

but despite repeated examination no diverticula could bedemonstrated macroscopically or microscopically.

THE DIFFERENTIAL DIAGNOSIS BETWEEN CROHN'SDISEASE AND DIVERTICULITIS

1 CLINICAL The records were examined of a con-secutive series of 50 patients who had a primaryresection at St. Mark's Hospital for diverticulosisor diverticulitis of the sigmoid colon and in whomno other lesion was found, either clinically or patho-logically, to account for their symptoms. The clinicalfeatures in this series are set out in the Table andcompared with the clinical features of the 26patients with Crohn's disease and divrerticula of thesigmoid colon.

It will be seen from the Table that the age inci-dence was about the same whether or not diverticulawere associated with Crohn's disease. However, thesex incidence was reversed: diverticula alone weremore common in men and combined disease wascommoner in women. Bleeding was more frequentin those with combined disease while abdominalpain was commoner in those with diverticulabut no Crohn's disease.

TABLECLINICAL FEATURES IN 50 PATIENTS OPERATED

UPON FOR DIVERTICULOSIS OR ITS COMPL;CATIONSCOMPARED WITH THOSE IN 26 PATIENTS WITHi

BOTH CROHN'S DISEASE AND COLONIC DIVERTICULADiverticula withoutCrohn's Disease(50 patients)

Diverticula withCrohn, Disease(26 patients)

Age

fixed pelvic mass had been felt, and an oedematoushaemorrhagic mucosa seen on sigmoidoscopy. Laparo-tomy revealed an inflammatory mass in the lower thirdof the sigmoid colon with thickening of the proximaltwo-thirds. A diagnosis of diverticulitis was made and aloop colostomy performed. Rectal biopsies were reportedas showing active chronic inflammatory changes withpartial ulceration of the mucosa.

After transfer to St. Mark's Hospital, no anal lesionswere found and sigmoidoscopy showed an oedematousand granular mucosa with blood and pus coming fromhigher in the bowel. The diagnosis was thought to liebetween Crohn's disease and diverticulitis. Barium enemaand barium introduced via the distal loop of the colo-stomy (Figs. 10 and 11) showed diverticula in the de-scending colon together with narrowing and a spikyappearance reminiscent of previous cases in whichCrohn's disease and diverticula were associated. A rectalbiopsy was highly suggestive of Crohn's disease. Sigmoidresection was performed and histological examinationconfirmed the presence of Crohn's disease of the sigmoid

RarMer

Sex 331SymptomsConstipation 16Diarrhoea 20Bleeding 18Mucus discharge ISAbdominal pain 41Weight loss 16

Physical FindingsAbdominal mass 10Anal lesion 0Recto-vaginal fistula 0

SigmoidoscopyNormal 39Abnormal 1 1

PostoperativeComplicationsSlow wound healing 0Anal or recto-vaginal 1fistulaeAnal fissure 0Breakdown 0anastomosis

Ontive50

nge 39 to 86 years Range 4& to 80 yearsan 57-6 years Mean 62 yearsM 17F 1IM ISF

(32 V.)(40%)(36%)(30%)(8,2%Y)(32%)

216207

3

(2%) 0(0%.) 22(0%Y) 3

(8%)(62%)(77%)(27%(19%)(12%)

(0%)(85%)(125)

(78%°) 3 (12%)(22.%) 23 (88%)

2S

23

ly one postopera- Total 12 postope complication in complications itresections seven of 14 pati

treated by rsec

erativenicnts:tion

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FIG. 1 0. FIG. 1 1.

FIG. 10. Case 6: the proximal sigmoid shows an asymmetrical fold pattern suggestive of diverticular disease. Therelatively long looped middle segment fills out fairly well, but the distal sigmoid is irregularly narrowed andfissured. Theappearances in the distal segment are due to Crohn's disease; no diverticula were seen in the specimen.

FIG. 11. Case 6: enema via distal loop ofcolostomy. The sigmoidshows diverticula and asymmetricalfolding, but there isalso some fine transversefissuring. It is hardly possible to make a radiological diagnosis ofCrohn's disease here.

The incidence of anal lesions in the two groupswas strikingly different. In patients with combineddisease, 22 of 26 had anal lesions characteristicofCrohn's disease (Lockhart-Mummeryand Morson,1964) and two others had recto-vaginal fistulae.In contrast no anal lesions were present in the 50patients with diverticula alone.Another marked difference between the two

groups was the high incidence of sigmoidoscopicabnormalities among those with combined disease.The rectal mucosa was abnormal in 19 (friable,granular, nodular, or ulcerated) of the 26 suchpatients; three others showed blood or mucopus inthe lumen without mucosal change, and stenosisof the anal canal was present in another. In contrastthe sigmoidoscopic appearances were abnormal inonly 11 of the 50 patients with diverticula alone;seven showed mucosal changes and four had anormal mucosa but with blood or pus present inthe lumen.The distinction between the two groups is shown

to be of practical importance in treatment by thehigh incidence of postoperative complications afterresection. Among those with combined diseaseseven of the 14 patients developed postoperativecomplications: in three the colonic anastomosisbroke down to give an external fistula; three de-veloped recto-vaginal fistula; the wound healedslowly in two, and chronic anal fissures and fistulaealso occurred. The only such complication among50 patients with diverticula alone was an analfistula.

2 RADIOLOGICAL Uncomplicated diverticular diseasecan be recognized by a deep, asymmetrical foldpattern almost always accompanied by diverticula.Diverticulitis may lead to abscess formation, aninternal fistula, or fibrosis (Young, 1965). It may beimpossible to differentiate the changes of Crohn'sand diverticular disease when both affect the samesegment of colon and, as already shown, !Crohn'sdisease may be mistaken for diverticular disease.

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The following radiological features have been foundhelpful in diagnosis.An internal or external fistula should suggest the

possibility of Crohn's disease. Very deep, narrowspurs of barium (Fig. 4) are unusual in diverticulardisease. When the radiologist sees narrowing of thesigmoid with barium projecting in long, thin streaksat right angles to the axis of the bowel, he may be indoubt as to whether this represents the close-packedfolds of diverticular disease or the fissuring ofCrohn's disease. If the projections of barium show aregular asymmetry, and especially if they terminatein a sacculation, he is probably looking at diverti-cular disease. But if the projections are spiky, blindand haphazardly distributed, he should at leastconsider the possibility of Crohn's disease (Figs.9, 10, 11).

It is unusual for diverticular disease to involvemore than the sigmoid colon and an inflammatorylesion of unusual extent suggests additional path-ology (Fig. 5). Any abnormality of the large bowelat a distance from the diverticula, for examplemucosal ulceration, should also suggest an asso-ciated condition. Similarly rectal abnormalities suchas a granular mucosal pattern, narrowing with anincreased recto-sacral distance, or frank ulcerationare not features of diverticular disease (Fig. 9). Forthis reason, it is essential that the barium enemafilms should include films of the rectum and alwaysinclude one lateral view.

3 PATHOLOGICAL The diagnosis of Crohn's diseaseand diverticulitis was made by examination ofresected specimens of diseased bowel in 14 of the 26patients included in this study. In all these cases thediverticular disease mainly affected the sigmoidcolon, but the Crohn's disease often involved otherparts of the large intestine or anus as well. Thecriteria for the pathological diagnosis of diverti-cular disease (Morson, 1963) and of Crohn's disease(Hadfield, 1939; Lockhart-Mummery and Morson,1960, 1964) have been described elsewhere.Macroscopic appearances In specimens of com-

bined Crohn's disease and diverticulitis the charac-teristic features of diverticular disease are easilyrecognizable by macroscopic examination. It is thepresence of diverticula with the muscular thickeningand corrugation of the bowel wall which are im-portant. Indeed, the first impression given by examinawtion of these specimens was obvious diverticulardisease with extensive pericolic inflammation.Closer inspection, however, revealed additionalfeatures not usually associated with diverticulitis.The mucous membrane of the sigmoid colon in

diverticulitis usually appears normal except for theredundancy consequent upon the muscular shorten-

ing. Redundancy was a feature of some of thespecimens of combined Crohn's disease and diverti-culitis reported here but in addition all cases showedmucosal inflammation. This took the form of, agranular appearance with oedema and mucosalthickening, often with patches of full-thicknessulceration of the mucous membrane. This wasvariable in extent and was associated in two caseswith inflammatory polyp formation due to under-mining of mucosa adjacent to areas of ulceration.The mucosal inflammation was not particularlyassociated with the orifices of diverticula, althoughin one case (Fig. 2) this was rather prominent.The cut surface of the bowel wall showed evidenceof transmural and extramural inflammation, whereasin uncomplicated diverticulitis the inflammatorycomponent of the pathology is exclusively pericolicin position. The fissuring so characteristic of Crohn'sdisease was present (Figs. 3 and 7) in most of thesecases, but is best observed at a microscopic levelof observation.

Microscopic appearances The most reliablecriteria for the diagnosis of Crohn's disease are thepresence of a granulomatous or sarcoid type oftissue response with a transmural type of inflamma-tion and fissuring of the bowel wall. In the specimensof Crohn's disease and diverticulitis reported herethe foimer diagnosis depended upon the presenceof a sarcoid type of tissue response which was presentin the bowel wall in all cases and in the regionallymphatic glands in 11 out of the 14 surgical speci-mens. These sarcoid foci were found in the mucosa,submucosa, and muscle layers as well as in thepericolic tissues. Fissuring could be found in mostcases but was especially prominent in three. It couldbe distinguished, even macroscopically in somespecimens, from the breaching of the bowel wallby diverticula. Transmural inflammation withwidening and oedema of the submucosa, togetherwith many foci of lymphoid tissue, was also charac-teristic. These microscopic features were present inaddition to the diverticula and muscular changesof diverticular disease.The inflammation in diverticulitis is extramural.

Foci of lymphoid tissue are commonly seen aroundchronic pericolic abscess cavities but do not involvethe submucosal and deep muscular layers of thebowel wall. Intramural fissuring is not a feature ofdiverticulitis and a true sarcoid reaction is never seenin the bowel wall or regional lymph nodes. However,the distinction between a foreign-body giant cellreaction in the neighbourhood of pericolic abscessesin diverticulitis and a true sarcoid reaction may notbe easy. In most of such cases, however, the giantcells are arranged around material obviously offaecal origin or else they are clearly foreign body

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Crohn's disease of the colon and its distinction from diverticulitis 15

rather than the Langhans type. Moreover, it mustbe emphasized that a giant cell reaction in diverti-culitis is extramural around infected diverticula.

Diagnosis of Crohn's disease in biopsies of therectum and anal lesions In 12 patients the diagnosisof Crohn's disease was made by rectal biopsy orbiopsy of an anal lesion. The principal diagnosticfeature in all cases was the presence of sarcoidgranulomata as described in previous papers(Morson and Lockhart-Mummery, 1959; Lockhart-Mummery and Morson, 1964).

DISCUSSION

Review of the literature on Crohn's disease of thecolon and on diverticulosis has revealed few referen-ces to this problem of combined disease. Lockhart-Mummery and Morson (1964) pointed out thatthe clinical distinction between Crohn's disease anddiverticulosis of the sigmoid colon is not alwayseasy, and Marganoff (1966) has indicated that itmay be difficult to differentiate early localized lesionsof Crohn's disease from carcinoma and diverti-culitis.The importance of diagnosing the presence of

Crohn's disease is suggested by the fact that of thenine patients in this series operated on with apreoperative diagnosis of'diverticulitis', sixdevelopedpostoperative complications (breakdown of ana-stomosis with cutaneous fistula, two fistula-in-ano,and two slow wound healing). On the other hand,of the four patients diagnosed as having Crohn'sdisease and diverticula preoperatively, only onedeveloped a postoperative complication (ano-rectalsuppuration). If cutaneous fistula or ano-rectalc.)mplications develop after a resection for 'diverti-culitis' Crohn's disease should be considered, andthe resected specimen or any biopsy material shouldbe re-examined with this possibility in mind.The knowledge that Crohn's disease is present

may also incline the clinician towards medicalmanagement, rather than sigmoid resection, insome cases. Sulphonamides appear to benefit someof these patients; in others topical or systemiccorticosteroids may be most useful, whereas thesedrugs would not be used for the treatment ofdiverticulitis.Whatever part of the gastrointestinal tract is

involved only about half of all patients with Crohn'sdisease have a sarcoid type of tissue response. Theprecise incidence largely depends on how energeti-cally the search for granulomas is pursued. In somecases these are sparsely distributed. Althoughgranulomas were present in all the 26 cases reportedhere it is likely that Crohn's disease and diverti-culitis may coexist in the sigmoid colon in the absence

of granulomas. In such cases the pathologicaldiagnosis would be difficult and the diagnosis ofCrohn's disease would depend on other features,such as transmural inflammation and fissuring. Thissituation has not yet arisen in our experience, butit is possible that the diagnosis of 'diverticulitis'alone has been made in patients who also haveunrecognized Crohn's disease in addition to diverti-cula. In such a situation the findings of a clinicallycharacteristic anal lesion or proctitis in associationwith sigmoid diverticulitis would lead at least to asuspicion of Crohn's disease.

SUMMARY

Twenty-six patients in whom Crohn's diseaseoccurred in a segment of bowel containing diverti-cula have been reviewed. In 14 of the patiepts thediagnosis was made by examination of a resectedspecimen; in 12 it was made by examination ofbiopsy material from the anus or rectal mucosa.

Twenty-four of the 26 patients had an anal lesionor recto-vaginal fistula and in 23 there were ab-normal findings on sigmoidoscopy. In only onepatient did the anus and rectum appear normaLbut rectal mucosal biopsy was abnoimal. Thesefeatures were more common than among 50 patientsoperated on for diverticulosis, or its complications,alone.

Radiologically, Crohn's disease in the presence ofdiverticula was suggested by unusual fissuring, amucosal lesion involving the rectum or colon awayfrom the area of diverticular disease, or a fistula.

Biopsy revealed non-caseating giant-cell granulo-mata in 10 of 1 1 biopsies of anal lesions and 12 of 13biopsies from the rectal mucosa. Pathologicalexamination of resected specimens from patientswith combined disease showed a diffuse mucosallesion, transmural inflammation with the presenceof fissures and non-caseating giant-cell systems.The distinction between Crohn's disease and

diverticulitis may be important in treatment. Post-operative complications were more common afterresection in patients with combined disease thanafter resection for diverticulosis or its complicationsalone. The knowledge that Crohn's disease is presentmay affect medical management, particularly re-garding the use of corticosteroids.We thank our colleagues at St. Mark's Hospital for theirhelp in this study, and the St. Mark's Research Foun-dation and the Research Endowment Fund of theHospital for financial support.

REFERENCES

Arfwidsson, S. (1964). Pathogenesis of multiple diverticula of thesigmoid colon in diverticular disease. Acta chir. scand., suppl.342.

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16 G. T. Schmidt, J. E. Lennard-Jones, B. C. Morson, and A. C. Young

Brooke, B. N. (1959). Granulomatous diseases of the intestine.Lancet, 2, 745-749.

Crohn, B. B., and Yarnis, H. (1958). Regional Ileitis, 2nd ed. Gruneand Stratton. New York and London.

Dearlove, T. P. (1954). Diverticulitis and diverticulosis, with a reporton a rare complication. Med. J. Aust., 1, 470-475.

Hadfield, G. (1939). The primary histological lesion of regionalileitis. Lancet, 2, 773-775.

Lindner, A. E., Marshak, R. H., Wolf, B. S., and Janowitz, H. D.(1963). Granulomatous colitis: a clinical study. New Engl. J.Med., 269, 379-385.

Lockhart-Mummery, H. E., and Morson, B. C. (1960). Crohn'sdisease (regional enteritis) of the large intestine and its distinc-tion from ulcerative colitis. Gut, 1, 87-105.

,- (19t4). Crohn's disease of the large intestine. Ibid., 5,493-509.

Marganoff, H. (1966). Anorectal lesions associated with granulomatouscolitis. Dis. Colon Rect., 9, 49-57.

Morson, B. C., and Lockhart-Mummery, H. E. (1959). Anal lesions inCrohn's disease. Lancet, 2, 1122-1123.

Morson, B. C. (1963). The muscle abnormality in diverticular diseaseof the sigmoid colon. Brit. J. Radiol., 36, 385-392.

Pemberton, J. deJ., Black, B. M., and Maino, C. R. (1947). Progressin the surgical management of diverticulitis of the sigmoidcolon. Surg. Gynec. Obstet., 85, 523-534.

Williams, I. (1963). Changing emphasis in diverticular disease of thecolon. Brit. J. Radiol., 36, 393-406.

Young, A. C. (1965). In panel discussion on surgical managementof diverticulitis. Dis. Colon Rect., 8, 167-169.

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Documents

Crohn's disease · Crohn's disease ofthe colon andits distinction fromdiverticulitis G. T. SCHMIDT, J. E. LENNARD-JONES, B. C. MORSON, AND A. C. YOUNG FromSt. Mark'sHospital, London