Discovery of Crohn's disease at celiotomy

Many patients with Crohn's disease have abdominal operations, but the role of surgical exploration in the recognition of this syndrome has not been assessed. We reviewed the operative records of 78 patients with a presumptive diagnosis of Crohn's disease who had a celiotomy between 1968 and 1979 at The University of Iowa Hospitals and Clinics. The patients were divided into two groups according to the likelihood of having Crohn's disease. Clinical presentation and operative indications were similar to those commonly reported for Crohn's disease. Most findings at celiotomy occurred with similar frequency in the two groups. Fat wrapping and thickening of the intestinal wall were the most common findings. These were closely followed in frequency of occurrence by the presence of adhesions, abdominal masses or serosal changes. Less common changes included strictures, intestinal dilation, skip lesions, fistulas and abscesses. Free peritoneal fluid and mesenteric lymph node enlargement were rare in 63 patients with established Crohn's disease but were comparatively more common in 15 patients deemed unlikely to have the disease. Even though the diagnosis of Crohn's disease was not firmly established preoperatively in more than one-fourth of the patients, the surgeon rarely took steps to make a specific diagnosis. Preoperatively, the diagnosis in four patients was changed from carcinoma of the cecum in two, from appendicitis in two and from ischemic colitis in one patient to a correct diagnosis of Crohn's disease, but never was a diagnosis preoperatively of Crohn's disease changed postoperatively to an alternative. We conclude that presently recognized operative findings are of limited value in the differential diagnosis of the disease because, in our experience, the preoperative diagnosis of Crohn's disease was never altered at operation. The diagnosis should be made with caution in the presence of free peritoneal fluid or mesenteric lymphadenopathy.