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Acute ileitis

Article  in  British Medical Journal (Clinical research ed.) · November 1981

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C. A. O’Morain
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caused by acute fatty liver of pregnancy. Epidural anaesthesia adults. Some patients have associated erythema nodosum and
is preferable, and should be preceded when necessary by trans- polyarthritis.'0 Many of the patients have operations for
fusion of fresh-frozen plasma and fresh platelet concentrate to appendicitis suspected on clinical grounds; typically the
avoid excessive bleeding during delivery. In other respects the surgeon finds an inflamed terminal ileum, with local lymph-
management of fulminant hepatic failure is the same as in non- adenopathy. The appendix and caecum may also be affected.
pregnant women.'3 The cause of the acute ileitis cannot be determined from the
ROGER WILLIAMS mnacroscopic appearances. Appendicectomy should be per-
R J EDE formed in these cases; it does not increase the risk of fistula
Liver Unit, formation even if the patient has Crohn's disease. Fistula
King's College Hospital Medical School,
London SE5 8RX formation in Crohn's disease is related to the severity of the
disease in the ileum and develops from the ileum and not the
Khuroo MS, Teli MR, Skidmore S, Sofi MA, Khuroo MI. Incidence and appendiceal stalk.1" The radiological characteristics of yersinia
severity of viral hepatitis in pregnancy. Am Y Med 1981 ;70:252-5. infection12 are a nodular pattern of the terminal ileum reflecting
2Sever J, White LR. Intrauterine viral infections. Annu Rev Med 1968;19:
47 1-8. oedema of the bowel, hyperplasia of intestinal lymphoid
: Haemmerli UP. Jaundice during pregnancy. Acta Med Scand 1966;179, tissue, and enlargement of regional lymph nodes. These
suppl 444 :9-1 1 1. features also occur in Crohn's disease. Nevertheless, abscess
' Borhanmanesh F, Haghighi P, Hekmat K, Rezaizadch K, Ghavami AG.
Viral hepatitis during pregnancy. Gastroenterology 1973;64 :304-12. or fistula formation, stenosis, pseudodiverticula, skip lesions,
Siegel M, Fuerst HT, Peress NS. Comparative fetal mortality in maternal and signs of appreciable thickening of the intestinal wall are
virus diseases. A prospective study on rubella, measles, mumps, chicken
pox and hepatitis. N EnglJ3 Med 1966;274:768-71. never observed in yersinia ileitis. The histological features of
Hieber JP, Dalton D, Shorey J, Combes B. Hepatitis and pregnancy. -7 infection with Y enterocolitica are non-specific transmural
Pediatr 1977;91:545-9. inflammation with a predominant polymorph infiltrate and
7Stoller A, Collmann RD. Incidence of infective hepatitis followed by
Down's syndrome nine months later. Lancet 1965;ii:1221-30. mucosal ulceration.'3 Granuloma formation is not found even
1 Dietzman
DE, Madden DL, Sever JL, Lander JJ, Purcell RH. Lack of in serial sections. When the organism responsible is Y pseudo-
relationship between Down's syndrome and maternal exposure to tuberculosis four histological stages may be distinguished:
Australia antigen. Am 7 Dis Child 1972;124:195-7.
9 Stevens CE, Beasley RP, Tsui J, Lee W-C. Vertical transmission of lymphoid hyperplasia, diffuse histiocytic cell hyperplasia,
hepatitis B antigen in Taiwan. N EnglJf Med 1975;292:771-4. epithelioid granuloma, and central coagulative necrosis of the
Derso A, Boxall EH, Tarlow MJ, Flewett TH. Transmission of HBsAg
from mother to infant in four ethnic groups. Br MedJ3 1978;i:949-52. granuloma with abscess formation.'4
"Alberti A, Diana S, Scullard GH, Eddleston ALWF, Williams R. Full When the colon is affected small ulcers, resembling aphthoid
and empty Dane particles in chronic hepatitis B virus infection: relation ulcers of Crohn's disease, may be seen on sigmoidoscopy or
to hepatitis B e antigen and presence of liver change. Gastroenterology
1978 ;75 :869-74. colonoscopy, but yersinia infection rarely mimics colonic
'2 Beasley RP, Stevens CE. Vertical transmission of HBV and interruption Crohn's disease.15 The diagnosis is made by culturing the
with globulin. In: Vyas GN, Cohen SN, Schmid R, eds. Viral hepatitis. organism from the stool or from a swab at appendicectomy.
Tunbridge Wells: Abacus Press, 1979:333-45.
13 Braude S, Gimson AES, Williams R. Progress in the management of Circulating antibodies to Y enterocolitica may be detected
fulminant hepatic failure. Intensive Care Med 1981 ;7:101-3. after six to seven days and their titre shows a peak at two to
three weeks; a rising titre is diagnostic. Titres of 1/50 may be
found in asymptomatic patients, but titres of 1/100 or greater
are associated with clinical disease (N S Mair). The blood
test may need to be repeated to make the diagnosis. In con-
Acute ileitis trast, antibodies to Y pseudotuberculosis are usually present
with the onset of symptoms. Yersinia infection usually
Acute ileitis is relatively rare. Its incidence is one case per resolves spontaneously, with patients becoming symptom
million population' compared with 40 to 80 per million for free after two to three weeks. Tetracycline is the drug of
Crohn's disease.2 3 Furthermore, acute terminal ileitis usually choice for patients with complications such as erythema
resolves spontaneously and does not show the chronicity of nodosum, polyarthritis, persisting diarrhoea, and fever.8 9
Crohn's disease. The two conditions cannot always be Yersinia infection never progresses to Crohn's disease.'0
distinguished: patients with Crohn's disease can present Recurrence of symptoms, chronicity, or late complications
acutely with symptoms resembling appendicitis, and a related to the gastrointestinal tract do not occur. An acute
diagnostic overlap is likely to persist until the cause of Crohn's arthritis caused by Y enterocolitica infection may nevertheless
disease is determined. In some series 10-20%/ of patients with cause long-term complications, including ankylosing spondy-
acute terminal ileitis go on to develop Crohn's disease.4-6 litis, sacroiliitis, and even seropositive rheumatoid arthritis.'6
The commonest identifiable cause of acute terminal ileitis If infection with yersinia is not found other conditions that
is infection by Yersinia enterocolitica7 and Ypseudotuberculosis,8 then cause terminal ileitis should be considered, such as
which accounts for 50 to 80% of cases.9 Yersinia are Gram- tuberculosis, tularaemia, amoebiasis, actinomycosis, schisto-
negative rods resembling non-lactose-fermenting Escherichia somiasis, and infestation with the larvae of the fish nematode
coli in morphology. Clinicians are becoming more aware of Anisakis. Crohn's disease has been reported as presenting
yersinia infections, which are being diagnosed more often. acutely with symptoms of acute appendicitis and free
Only 0-5% of 475 patients with abdominal symptoms seen perforation'7; so that in patients in whom no other cause is
in 1975 were found to have antibodies to Y enterocolitica found the wheel turns full circle.
compared with 2-7% of sera from 1233 patients examined in c 6 MORAIN
1980 at the yersinia reference laboratory in Leicester (N S Mair, Honorary Senior Registrar,
Division of Clinical Sciences,
"Yersinia infection in the UK and Eire with special reference Clinical Research Centre,
to yersinia enterocolitica," paper given at the WHO meeting London HAl 3UJ
in Paris in April 1981). The clinical manifestations of yersinia
infection include acute enteritis, fever, and diarrhoea in
I Hoj L, Jensen PB, Bonnevie 0, Riis P. An epidemiological study of
regional enteritis and acute ileitis in Copenhagen County. Scand J
children, and an acute terminal ileitis or mesenteric adenitis in Gastroenterol 1973 ;8 :381-4.
1076 BRITISH MEDICAL JOURNAL VOLUME 283 24 OCTOBER 1981

2 Kyle J, Stark G. Fall in the incidence of Crohn's disease. Gut 1980;21: when there was a departure from accepted standards of
340-3.
3 Mayberry JF, Rhodes J, Hughes LE. Incidence of Crohn's disease in satisfactory care and where an alternative form of management
Cardiff between 1934 and 1977. Gut 1979;20:602-8. might have prevented or reduced the likelihood of death.)
4 Crohn BB. The pathology of acute regional ileitis. American Journal of
Digestive Diseases 1965 ;10 :565-72.
The same series of reports has given more precise information
5 Sjoestrom B. Acute terminal ileitis and its relation to Crohn's disease. about the causes of death in these cases. Some complication
In: Engel A, Larsson T, eds. Regional enteritis (Crohn's disease). 5th associated with the anaesthetic is the most frequent single
Skandia International Symposium, Stockholm, 1970. Stockholm: cause of death after caesarean section-it accounts for 20%
Nordiska Bokhandeln Forlag, 1971 :73-80.
6 Kewenter J, Hulten L, Kock NG. The relationship and epidemiology of of all deaths. This cause of death is doubly important in that
acute terminal ileitis and Crohn's disease. Gut 1974;15:801-4.
7 Winblad S, Niiehn B, Sternby NH. Yersinia enterocolitica (Pasteurella X)
avoidable factors are present in all but a few cases. Haemorrhage
in human cnteric infections. Br Med3' 1966;ii:1363-6. and sepsis are the other causes that are largely avoidable;
8 Gurry JF. Acute terminal ileitis and yersinia infection. Br MedJ7 1974;ii: pulmonary embolism is a partly avoidable cause.4 5
264-6. The choice between vaginal and abdominal delivery
9 Jess P. Acute terminal ileitis. A review of recent literature on relationship
to Crohn's disease. ScandJ3 Gastroenterol 1981 ;16:321-4. depends on how the obstetrician sees the balance of risks,
10 Vantrappen G, Agg HO, Ponette E, Geboes K, Bertrand Ph. Yersinia and the decision is personal and specific to a given case. One
enteritis and enterocolitis: gastroenterological aspects. Gastroenterology important factor is his concern to avoid any accusation of
1977 ;72 :220-7.
Gump FE, Lepore M, Barker HG. A revised concept of acute regional failure to intervene when caesarean section might arguably
enteritis. Ann Surg 1967;166:942-6.
12 Ekberg 0, Sjostrom B, Brahme F. Radiological findings in yersinia ileitis.
have led to safer delivery for the mother and especially for
Radiology 1977;123:15-9. the child. Conceivably electronic fetal monitoring,6 used
13 Bradford WD, Noce PS, Gutman LT. Pathologic features of enteric uncritically, could have led to an increase in caesarean
infection with Yersinia enterocolitica. Archives of Pathology 1974;98: sections.7 Another noticeable development is the delivery of
17-22.
14 El-Maraghi NRH, Mair NS. The histopathology of enteric infection with more breech babies, especially small ones, by caesarean
Yersinia pseudotuberculosis. AmJ Clin Pathol 1979;71:631-4. section.8 9
15 Swarbrick ET, Kingham JGC, Price HL, et al. Chlamydia, cytomegalo-
virus, and yersinia in inflammatory bowel disease. Lancet 1979;ii :11-2.
The wisdom of this increase in the proportion of abdominal
16 Marsal L, Winblad S, Wollheim FA. Yersinia enterocolitica arthritis in deliveries has been challenged by Francome and Huntingford,6
southern Sweden: a four-year follow-up study. Br Med J 1981;283: who remain unconvinced that the trend is in the best interests
101-3. of mothers or babies. On the basis of their own experience
17 Janevicius RV, Bartolome JS, Schmitz RL. Acute free perforation as a
presenting sign of regional enteritis. Case report and collective review in London and a review of reports of other series they do not
of the literature. Am J Gastroenterol 1980;74:143-9. believe that a case has yet been made for a caesarean section
rate over 60%. Quoting Baird's assessment of social influences
on the efficiency of reproduction,10 they argue that the
improvements in maternal and fetal mortality rates in the
past 25 years have come more from socioeconomic progress
Caesarean section than from readier recourse to surgical intervention. Their
challenge of the evidence on which the increasing trend
The proportion of babies delivered by caesarean section has towards delivery by caesarean section is based is refreshing
been rising steadily in Britain and North America for many and helpful. As with other techniques of intervention in
years. In 1963 in England and Wales the figure was 3-1%0, labour, we need more sound, scientific evidence that caesarean
and by 1978 it had risen to 7.5%.2 In the United States the section is in the best interests of mother and child. In the
rise has been even more dramatic-from 5-5%/ in 1970 to meantime the obstetrician must decide on the safest method
of delivery by weighing up all the considerations in the
15.2% in 1978-and it is continuing.3 These are national individual case-keeping in mind his own experience and the
figures. In individual hospitals the rates vary greatly and
reflect the practice of the medical staff as well as the types of facilities available to him.
patients they are dealing with. J K RUSSELL
Professor of Obstetrics and Gynaecology,
The fact that caesarean section is safer than it has ever been University of Newcastle upon Tyne,
contributes to its increased use. But it remains a major surgical Princess Mary Maternity Hospital,
Newcastle upon Tyne NE2 3BD
procedure that is not without risk. The death rate for 1000
caesarean sections in England and Wales fell from 1-3 in 1964 'General Register Office. Report on hospitalin-patient enquiry 1963. London:
to 0-7 in 1975,4 and the figures in the United States are broadly Ministry of Health and General Register Office, 1967.
comparable.35 This is several times the overall maternal 2 Office of Population Censuses and Surveys. Maternity statistics 1978.
London: OPCS, 1981 (OPCS Monitor MB4 81/1.)
death rate for England and Wales, which was 0-1 per 1000 3 National Institutes of Health. Cesarean childbirth. Consensus development
total births in 1975.4 We cannot, of course, compare direct conference summary. Vol 3. No 6. Bethesda: National Institutes of
the figures for the two methods of delivery or even determine Health, 1981.
4 Department of Health and Social Security. Report on confidential enquiries
the inherent risk of elective caesarean section, where so much into maternal deaths in England and Wales 1973-1975. London: HMSO,
depends on the patient's condition, the skill of the operator, 1979. (Reports on Health and Social Subjects, No. 14.)
a Rubin GL, Peterson HB, Rochat RW, McCarthy BJ, Terry JS. Maternal
and, not least, the experience and skill of the anaesthetist. death after cesarean section in Georgia. AmJI Obstet Gynecol 1981 ;139:
Some of the maternal deaths that occur after caesarean section 681-5.
can reasonably be attributed to the complications that Francome C, Huntingford APJ. Birth by caesarean section in the United
States of America and in Britain. Y Biosoc Sci 1980;12:353-62.
necessitated the operation, but the series of Report on Jones OH. Cesarean section in present-day obstetrics. AmJ Obstet Gynecol
Confidential Enquiries into Maternal Deaths in England and 1976 ;126 :521-30.
Wales has shown an increasing percentage of deaths with Karp LE, Doney JR, McCarthy T, Meis PJ, Hall M. The premature
breech: trial of labor or cesarean section? Obstet Gynecol 1979;53:
avoidable factors: in 1952-4, 30%o were judged to have 88-92.
avoidable factors, but more recent reports give proportions 9 Ingemarsson I, Westgren M, Svenningsen NW. Long-term follow-up of
preterm infants in breech presentation delivered by caesarean section.
of 5000 and even 60%.4 (Regional assessors, after considering A prospective study. Lancet 1978;ii:172-5.
the circumstances of each death, record an avoidable factor ' Baird D. The evolution of modern obstetrics. Lancet 1960;ii:557-64.

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