Crohn's disease: course, treatment and long term prognosis.
The course, treatment and outcome of Crohn's disease affecting 174 patients diagnosed more than 20 years ago and followed for 20 to 45 years are reported. Fifty patients died, 23 related to Crohn's disease, against an expected 33, giving an increased mortality risk of 1.5 for the series. Fistulae of varying type occurring in 38 per cent of patients were successfully treated usually by excision and had no significant adverse effect upon the long term prognosis. The incidence of suicide and dementia appeared to be increased. Amyloid disease, obstructive uropathy and osteomalacia were other important complications. Definitive surgical operations averaged 2.5 per patient and after the first five years following diagnosis varied between 5 and 7 per cent of those at risk each year for the next 20 years. Recurrence rates were similar after any of the first five operations on a patient for the first 10 years after any operation. There was no evidence that the chance of operation was increased or made to recur more frequently by the performance of such an operation. All but two of the 121 living patients (three lost to follow-up) with a mean duration since diagnosis of 28 years were leading a normal life free from physical restrictions from Crohn's disease though three were mentally handicapped, 21 had radiological abnormality (recurrence), mostly longstanding, and 16 had less than 200 cm small intestine remaining. Specific therapy (corticosteroids 58 patients, sulphasalazine 11 patients and azathioprine four patients) was used at some time in only one third of the series so that such treatment did not appear necessary to produce good results in the majority. It is concluded that the indications for corticosteroid therapy are limited and that at present the joint efforts of physician and surgeon with adequate supportive therapy and well timed surgical resection produce the best results. An optimistic attitude to the eventual outcome is justified.