Malignant colorectal strictures in Crohn's disease

Abstract

One hundred thirty-two of 980 patients (13.5%) with Crohn's disease (CD) involving the colon, admitted to The Mount Sinai Hospital between 1959 and 1985, developed 175 colonic strictures. Thirty-three patients developed more than one stricture. The frequency was twice as great in colitis (19%) as in ileocolitis (11%). Ten malignant strictures were identified in nine patients (three ileocolitis, six colitis). One of these patients had three strictures (two malignant, and one benign), and two had two strictures (one malignant and one benign). The frequency of cancer in patients with stricture (6.8%) was higher than in those without stricture (0.7%, six of 848, p less than 0.001). There were no differences in clinical symptoms between patients with benign and malignant stricture. Seventeen of 165 benign strictures (10.3%) were long, extending over more than one anatomical segment of colon, but all 10 malignant strictures were short (p less than 0.0001). The age at the diagnosis of stricture was higher in the nine patients with malignant stricture than in the 123 patients with benign stricture (mean age 57.2 vs. 41.4 yr, respectively, p less than 0.01). The proportion of strictures that were malignant increased with duration of disease from 3.3% with less than 20 yr of CD, to 11% with CD of 20 yr or more. All nine patients with malignant stricture were treated surgically, and four of the nine died of colon cancer during a mean follow-up of 4.3 yr. Prognosis was worse in six other nonstricture cancers in this series, with five colon cancer deaths during mean follow-up of 1.6 yr. In view of the high rate of malignancy, 6.8% in this series, colonoscopy with biopsy is essential in Crohn's disease patients with colonic strictures, and surgery must be considered when a stricture cannot be fully assessed during colonoscopy.