Journal of the Royal Society of Medicine Volume 71 June 1978
413
Nonspecific inflammatory bowel disease in two general hospitals' N A Buckell MB MRCP St Mark's Hospital, City Road, London EC] V 2PS
Summary During 1976, 50 patients were admitted to two general hospitals for the investigation or treatment of nonspecific inflammatory bowel disease. There were more patients admitted with Crohn's disease (23) than proctocolitis (11). Half of those patients admitted with Crohn's disease required surgical treatment, the majority for small bowel obstruction. Five patients were admitted for the treatment of an acute attack of proctocolitis; these patients were all previously undiagnosed, were all admitted urgently and all responded to medical treatment.
Introduction Detailed studies of patients with nonspecific inflammatory bowel disease admitted to special centres have been reported (Edwards & Truelove 1963, 1964, Truelove & Penia 1976, Atwell et al. 1965). Less is known about those patients admitted to district general hospitals and a prospective study has therefore been made of all patients with nonspecific inflammatory bowel disease admitted to two district hospitals. Definition and methods Nonspecific inflammatory bowel disease has been taken to include proctocolitis, Crohn's disease, ischaemic colitis, antibiotic-induced colitis and acute ileitis. Where it has not been possible to define the category of inflammatory bowel disease the diagnosis has been termed inflammatory bowel disease (IBD) (unspecified). While histological confirmation of the diagnosis is desirable, it is not always practicable. Cases have been included when a firm diagnosis has been made on the basis of the history, sigmoidoscopic findings and radiological examination of the small and/or large bowel and, on occasions, the appearance at laparotomy. Patients admitted for reasons unrelated to their inflammatory bowel disease have been included in a separate category. In these cases the diagnosis had usually been made previously, often at another hospital. All patients admitted to Enfield District Hospital, Chace Wing (431 beds) and to the North Middlesex Hospital (640 beds) between 1 January and 31 December 1976 inclusive were studied. Cases were ascertained by direct contact with the medical and nursing staff and regular visits to the wards of these hospitals. The admission record (North Middlesex Hospital) was studied and the histology reports, operating theatre registers and radiology records at both hospitals were examined frequently. The discharge coding registers were studied until 18 April 1977. The case records were examined whenever the diagnosis of inflammatory bowel disease was suggested by any of these sources and details of the illness were recorded on a proforma. When possible the patients were interviewed during their admission. 1 Accepted 27 February 1978 0 141-0768/78/0071--0413/$Ol .00/0
C
The Royal Society of Medicine 1978
414
Journal of the Royal Society of Medicine Volume 71 June 1978
Results There were 19 admissions of 15 patients to the North Middlesex Hospital and 40 admissions of 35 patients to the Enfield District Hospital, Chace Wing, for nonspecific inflammatory bowel disease during 1976. The number of admissions in each diagnostic category is shown in Table 1. During this period there were 28 485 discharges or deaths from the two hospitals, of which 10 388 were for general medical or general surgical disorders. Table 1. Number ofadmissions to two hospitals during 1976for each diagnostic category of nonspecific inflammatory bowel disease. (Number of patients in each category in parentheses) Diagnostic category
Chace Wing
Crohn's disease Proctocolitis IBD (unspecified) Ischaemic colitis Antibiotic colitis Acute ileitis Miscellaneous
21 7 8 1 1 1 1
(17) (7) (7) (1) (1) (1) (1)
North Middlesex 8 (6) 6 (4)
1 (1) 2 (2)
1(1) 1 (1)
Totals 29 (23) 13 (11) 9 (8) 3 (3) 1 (1) 2 (2) 2 (2)
Crohn's disease The mean age of the 23 patients in this group was 45 years and there was a preponderance of female patients (14 female, 9 male). These patients had an average of 2.2 previous admissions for Crohn's disease and 13 were known to have Crohn's disease at the time of this admission. The mean length of hospital stay was 15 days and there were no related deaths. Of the 23 patients with Crohn's disease, 11 were admitted for small bowel obstruction; operation was required in 8 of these patients, 3 of whom had recurrent disease after previous surgical treatment. One patient previously thought to have proctocolitis and one with unspecified inflammatory bowel disease were diagnosed as having Crohn's disease during their admission in 1976. Four patients with Crohn's disease were admitted for unrelated reasons, one of whom died following a myocardial infarction. Proctocolitis The mean age of the 11 patients admitted to hospital with proctocolitis was 55 years and the distribution of the sexes was 7 male and 4 female. These patients had an average of 0.7 previous admissions for proctocolitis and the mean length of hospital stay was 19 days. Five patients were admitted for the treatment of an acute attack of proctocolitis. All were previously undiagnosed and were admitted urgently (2 from outpatient clinics) to one of the hospitals. All responded to medical treatment. One of these patients, a man aged 86 years, died of myocardial ischaemia after remission of the colitis had been obtained with oral prednisolone. A sixth patient admitted for investigation of diarrhoea and subsequently found to have proctocolitis, died of cardiorespiratory failure while undergoing treatment for the colitis. One patient was treated electively by colectomy and ileorectal anastomosis for chronic disease. Four patients who had been treated surgically in previous years were readmitted; 2 with small bowel obstruction, one with renal failure due to pyelonephritis and one with iron deficiency anaemia. There were 12 patients with proctocolitis who were admitted for reasons unrelated to the colitis. Five of these patients required treatment with corticosteroids for active colitis during their admission.
Inflammatory bowel disease (unspecified) The mean age of these 8 patients was 46 years and there was no difference in the sex distribution
Journal of the Royal Society of Medicine Volume 71 June 1978
415
(4 males, 4 females). There was an average of 0.7 previous admissions for the inflammatory bowel disease. The mean length of hospital stay was nine days and there were no deaths. There was difficulty in differentiating Crohn's disease and ulcerative colitis in 6 patients. In 2 patients there was reason to suspect an ischaemic colitis, but the diagnosis could not be substantiated. Only one of these patients was admitted urgently, while 7 were admitted for investigation. None of these patients required surgical treatment; 3 patients were treated with corticosteroids. Discussion In London, the referral of any patient to a particular hospital is determined by a number of factors. These include the general practitioner's and patient's preference, the known interests of the hospital and the ease with which friends and relatives can visit. In cases requiring urgent admission the availability of beds may be the deciding factor. Therefore this study does not represent the number of admissions for inflammatory bowel disease in a defined population but the practice of two general hospitals, comprising 211 general medical and 158 general surgical beds, situated five miles apart in North London and eight miles from the nearest teaching or specialist hospital. A larger number of patients with inflammatory bowel disease was admitted to one of the hospitals. This may be due to chance or represent a difference in the special interests of the clinicians at the two hospitals. A difference in the natural incidences of the diseases in two areas situated so close together is unlikely. It is of interest that the number of admissions for Crohn's disease was about twice that for proctocolitis. This is in contrast with the higher prevalence of proctocolitis in the population (Evans & Acheson 1965) and the greater number of discharges for proctocolitis recorded by the Hospital In-Patient Enquiry in England and Wales throughout the period 1963-1973 (Medical Statistics Unit, Office of Population Censuses and Surveys). However, the number of discharges from hospital in England and Wales for Crohn's disease has been increasing over the last decade while that for proctocolitis has remained constant (Figure 1). Miller et al. (1974) 7000 6000\
Ulcerative colitis
5000
Regional
4000. Number of discharges
enteritis
3000/ 2000. (N B: Regional enteritis includes Crohn's disease and regional
1000
ileitis n
1963 '64 '65 '66 '67 '68 '69 '70 '71
'72 1973
Figure 1. The estimated total annual number of discharges from hospital in England and Wales for ulcerative colitis and regional enteritis. (Derived from Hospital In-Patient Enquiry)
416
Journal of the Royal Society of Medicine Volume 71 June 1978
also found an increasing frequency of admissions for Crohn's disease in the Nottingham area between 1958 and 1971. It is possible that the number of admissions for Crohn's disease will exceed those for proctocolitis in the near future. The natural history of Crohn's disease is such that repeated spells of inpatient treatment are often required and this is a factor influencing the greater number of admissions for Crohn's disease. The increased recognition of Crohn's colitis may also have influenced the changing ratio of admissions for proctocolitis and Crohn's disease. In this study, one patient originally thought to have proctocolits and one with inflammatory bowel disease (unspecified) were found to have Crohn's disease. The number of patients admitted with Crohn's disease (4) and proctocolitis (13) for reasons unrelated to nonspecific inflammatory bowel disease reflects the known prevalences more closely. It is also of note that there were only 5 admissions for the treatment of an attack of proctocolitis; all were patients in whom the diagnosis was unknown at the time of admission and all were admitted urgently. Five patients who were admitted for other reasons also had active proctocolitis requiring treatment with corticosteroids during their admission. None of these patients required surgical treatment. There were no patients with known proctocolitis admitted for the treatment of an attack, which probably reflects the effective outpatient management of this condition. Two patients with proctocolitis who had each had a colectomy and subsequent rectal excision presented with intestinal obstruction, seven and eight years respectively after the last operation. Intestinal obstruction following colectomy is particularly common in the first year after operation, although an increased risk probably persists throughout life (Ritchie 1972). In these two hospitals about one in two hundred medical and surgical admissions were for inflammatory bowel disease. Overall, surgical treatment was undertaken for about one-third of the patients; Crohn's disease was often a surgical problem and proctocolitis usually a medical one. Patients with unspecified inflammatory bowel disease presented particularly with diagnostic rather than therapeutic problems and it seems that the failure to make a precise pathological diagnosis did not interfere with the management of these patients, a number of whom required no specific treatment. Acknowledgments: I am grateful to the consultant medical staff at Enfield District Hospital, Chace Wing, and the North Middlesex Hospital for allowing me to study patients under their care and particularly Dr J D Kinloch and Mr R A Payne for their help; Mr S Horne, Area Planning Information Officer; and Professor J E Lennard-Jones for his helpful criticism. I also thank the junior medical staff, nursing staff, medical secretaries and the staff of the X-ray, Pathology and Records Departments. The staff of the Medical Statistics Unit of the Office of Population Censuses and Surveys kindly provided the data from the Hospital In-Patient
Enquiry. This work was undertaken while the author was in receipt of a LOCR grant from the North East Thames Regional Health Authority. References Atwell J D, Duthie H L & Goligher J C (1965) British Journal of Surgery 52, 966-972 Edwards F C & Truelove S C (1963) Gut 4, 299-315 Edwards F C & Truelove S C (1964) Gut 5, 1-22 Evans J G & Acheson E D (1965) Gut 6, 311-324 Miller D S, Keighley A C & Langman M J S (1974) Lancet ii, 691-693 Ritchie J K (1972) British Journal of Surgery 59, 345-351 Truelove S C & Pefia A S (1976) Gut 17, 192-201
413
Nonspecific inflammatory bowel disease in two general hospitals' N A Buckell MB MRCP St Mark's Hospital, City Road, London EC] V 2PS
Summary During 1976, 50 patients were admitted to two general hospitals for the investigation or treatment of nonspecific inflammatory bowel disease. There were more patients admitted with Crohn's disease (23) than proctocolitis (11). Half of those patients admitted with Crohn's disease required surgical treatment, the majority for small bowel obstruction. Five patients were admitted for the treatment of an acute attack of proctocolitis; these patients were all previously undiagnosed, were all admitted urgently and all responded to medical treatment.
Introduction Detailed studies of patients with nonspecific inflammatory bowel disease admitted to special centres have been reported (Edwards & Truelove 1963, 1964, Truelove & Penia 1976, Atwell et al. 1965). Less is known about those patients admitted to district general hospitals and a prospective study has therefore been made of all patients with nonspecific inflammatory bowel disease admitted to two district hospitals. Definition and methods Nonspecific inflammatory bowel disease has been taken to include proctocolitis, Crohn's disease, ischaemic colitis, antibiotic-induced colitis and acute ileitis. Where it has not been possible to define the category of inflammatory bowel disease the diagnosis has been termed inflammatory bowel disease (IBD) (unspecified). While histological confirmation of the diagnosis is desirable, it is not always practicable. Cases have been included when a firm diagnosis has been made on the basis of the history, sigmoidoscopic findings and radiological examination of the small and/or large bowel and, on occasions, the appearance at laparotomy. Patients admitted for reasons unrelated to their inflammatory bowel disease have been included in a separate category. In these cases the diagnosis had usually been made previously, often at another hospital. All patients admitted to Enfield District Hospital, Chace Wing (431 beds) and to the North Middlesex Hospital (640 beds) between 1 January and 31 December 1976 inclusive were studied. Cases were ascertained by direct contact with the medical and nursing staff and regular visits to the wards of these hospitals. The admission record (North Middlesex Hospital) was studied and the histology reports, operating theatre registers and radiology records at both hospitals were examined frequently. The discharge coding registers were studied until 18 April 1977. The case records were examined whenever the diagnosis of inflammatory bowel disease was suggested by any of these sources and details of the illness were recorded on a proforma. When possible the patients were interviewed during their admission. 1 Accepted 27 February 1978 0 141-0768/78/0071--0413/$Ol .00/0
C
The Royal Society of Medicine 1978
414
Journal of the Royal Society of Medicine Volume 71 June 1978
Results There were 19 admissions of 15 patients to the North Middlesex Hospital and 40 admissions of 35 patients to the Enfield District Hospital, Chace Wing, for nonspecific inflammatory bowel disease during 1976. The number of admissions in each diagnostic category is shown in Table 1. During this period there were 28 485 discharges or deaths from the two hospitals, of which 10 388 were for general medical or general surgical disorders. Table 1. Number ofadmissions to two hospitals during 1976for each diagnostic category of nonspecific inflammatory bowel disease. (Number of patients in each category in parentheses) Diagnostic category
Chace Wing
Crohn's disease Proctocolitis IBD (unspecified) Ischaemic colitis Antibiotic colitis Acute ileitis Miscellaneous
21 7 8 1 1 1 1
(17) (7) (7) (1) (1) (1) (1)
North Middlesex 8 (6) 6 (4)
1 (1) 2 (2)
1(1) 1 (1)
Totals 29 (23) 13 (11) 9 (8) 3 (3) 1 (1) 2 (2) 2 (2)
Crohn's disease The mean age of the 23 patients in this group was 45 years and there was a preponderance of female patients (14 female, 9 male). These patients had an average of 2.2 previous admissions for Crohn's disease and 13 were known to have Crohn's disease at the time of this admission. The mean length of hospital stay was 15 days and there were no related deaths. Of the 23 patients with Crohn's disease, 11 were admitted for small bowel obstruction; operation was required in 8 of these patients, 3 of whom had recurrent disease after previous surgical treatment. One patient previously thought to have proctocolitis and one with unspecified inflammatory bowel disease were diagnosed as having Crohn's disease during their admission in 1976. Four patients with Crohn's disease were admitted for unrelated reasons, one of whom died following a myocardial infarction. Proctocolitis The mean age of the 11 patients admitted to hospital with proctocolitis was 55 years and the distribution of the sexes was 7 male and 4 female. These patients had an average of 0.7 previous admissions for proctocolitis and the mean length of hospital stay was 19 days. Five patients were admitted for the treatment of an acute attack of proctocolitis. All were previously undiagnosed and were admitted urgently (2 from outpatient clinics) to one of the hospitals. All responded to medical treatment. One of these patients, a man aged 86 years, died of myocardial ischaemia after remission of the colitis had been obtained with oral prednisolone. A sixth patient admitted for investigation of diarrhoea and subsequently found to have proctocolitis, died of cardiorespiratory failure while undergoing treatment for the colitis. One patient was treated electively by colectomy and ileorectal anastomosis for chronic disease. Four patients who had been treated surgically in previous years were readmitted; 2 with small bowel obstruction, one with renal failure due to pyelonephritis and one with iron deficiency anaemia. There were 12 patients with proctocolitis who were admitted for reasons unrelated to the colitis. Five of these patients required treatment with corticosteroids for active colitis during their admission.
Inflammatory bowel disease (unspecified) The mean age of these 8 patients was 46 years and there was no difference in the sex distribution
Journal of the Royal Society of Medicine Volume 71 June 1978
415
(4 males, 4 females). There was an average of 0.7 previous admissions for the inflammatory bowel disease. The mean length of hospital stay was nine days and there were no deaths. There was difficulty in differentiating Crohn's disease and ulcerative colitis in 6 patients. In 2 patients there was reason to suspect an ischaemic colitis, but the diagnosis could not be substantiated. Only one of these patients was admitted urgently, while 7 were admitted for investigation. None of these patients required surgical treatment; 3 patients were treated with corticosteroids. Discussion In London, the referral of any patient to a particular hospital is determined by a number of factors. These include the general practitioner's and patient's preference, the known interests of the hospital and the ease with which friends and relatives can visit. In cases requiring urgent admission the availability of beds may be the deciding factor. Therefore this study does not represent the number of admissions for inflammatory bowel disease in a defined population but the practice of two general hospitals, comprising 211 general medical and 158 general surgical beds, situated five miles apart in North London and eight miles from the nearest teaching or specialist hospital. A larger number of patients with inflammatory bowel disease was admitted to one of the hospitals. This may be due to chance or represent a difference in the special interests of the clinicians at the two hospitals. A difference in the natural incidences of the diseases in two areas situated so close together is unlikely. It is of interest that the number of admissions for Crohn's disease was about twice that for proctocolitis. This is in contrast with the higher prevalence of proctocolitis in the population (Evans & Acheson 1965) and the greater number of discharges for proctocolitis recorded by the Hospital In-Patient Enquiry in England and Wales throughout the period 1963-1973 (Medical Statistics Unit, Office of Population Censuses and Surveys). However, the number of discharges from hospital in England and Wales for Crohn's disease has been increasing over the last decade while that for proctocolitis has remained constant (Figure 1). Miller et al. (1974) 7000 6000\
Ulcerative colitis
5000
Regional
4000. Number of discharges
enteritis
3000/ 2000. (N B: Regional enteritis includes Crohn's disease and regional
1000
ileitis n
1963 '64 '65 '66 '67 '68 '69 '70 '71
'72 1973
Figure 1. The estimated total annual number of discharges from hospital in England and Wales for ulcerative colitis and regional enteritis. (Derived from Hospital In-Patient Enquiry)
416
Journal of the Royal Society of Medicine Volume 71 June 1978
also found an increasing frequency of admissions for Crohn's disease in the Nottingham area between 1958 and 1971. It is possible that the number of admissions for Crohn's disease will exceed those for proctocolitis in the near future. The natural history of Crohn's disease is such that repeated spells of inpatient treatment are often required and this is a factor influencing the greater number of admissions for Crohn's disease. The increased recognition of Crohn's colitis may also have influenced the changing ratio of admissions for proctocolitis and Crohn's disease. In this study, one patient originally thought to have proctocolits and one with inflammatory bowel disease (unspecified) were found to have Crohn's disease. The number of patients admitted with Crohn's disease (4) and proctocolitis (13) for reasons unrelated to nonspecific inflammatory bowel disease reflects the known prevalences more closely. It is also of note that there were only 5 admissions for the treatment of an attack of proctocolitis; all were patients in whom the diagnosis was unknown at the time of admission and all were admitted urgently. Five patients who were admitted for other reasons also had active proctocolitis requiring treatment with corticosteroids during their admission. None of these patients required surgical treatment. There were no patients with known proctocolitis admitted for the treatment of an attack, which probably reflects the effective outpatient management of this condition. Two patients with proctocolitis who had each had a colectomy and subsequent rectal excision presented with intestinal obstruction, seven and eight years respectively after the last operation. Intestinal obstruction following colectomy is particularly common in the first year after operation, although an increased risk probably persists throughout life (Ritchie 1972). In these two hospitals about one in two hundred medical and surgical admissions were for inflammatory bowel disease. Overall, surgical treatment was undertaken for about one-third of the patients; Crohn's disease was often a surgical problem and proctocolitis usually a medical one. Patients with unspecified inflammatory bowel disease presented particularly with diagnostic rather than therapeutic problems and it seems that the failure to make a precise pathological diagnosis did not interfere with the management of these patients, a number of whom required no specific treatment. Acknowledgments: I am grateful to the consultant medical staff at Enfield District Hospital, Chace Wing, and the North Middlesex Hospital for allowing me to study patients under their care and particularly Dr J D Kinloch and Mr R A Payne for their help; Mr S Horne, Area Planning Information Officer; and Professor J E Lennard-Jones for his helpful criticism. I also thank the junior medical staff, nursing staff, medical secretaries and the staff of the X-ray, Pathology and Records Departments. The staff of the Medical Statistics Unit of the Office of Population Censuses and Surveys kindly provided the data from the Hospital In-Patient
Enquiry. This work was undertaken while the author was in receipt of a LOCR grant from the North East Thames Regional Health Authority. References Atwell J D, Duthie H L & Goligher J C (1965) British Journal of Surgery 52, 966-972 Edwards F C & Truelove S C (1963) Gut 4, 299-315 Edwards F C & Truelove S C (1964) Gut 5, 1-22 Evans J G & Acheson E D (1965) Gut 6, 311-324 Miller D S, Keighley A C & Langman M J S (1974) Lancet ii, 691-693 Ritchie J K (1972) British Journal of Surgery 59, 345-351 Truelove S C & Pefia A S (1976) Gut 17, 192-201
