Some
colectomy specimens from patients with severe
colitis contain superficial fissuring-type
ulcers but do not have any other features of
Crohn's disease (CD). This finding may cause difficulty with regard to distinguishing
ulcerative colitis (UC) from CD and, thus, lead to a diagnosis of "indeterminate"
colitis. The aim of this study was to evaluate the clinical and pathologic features, and outcome, of a cohort of patients with
colitis and superficial fissuring
ulcers, but without any other features that may suggest a diagnosis of CD. We retrospectively identified 21 patients (male-to-female ratio, 10/11; mean age, 38 years) with severe chronic active
colitis, all of whom had at least one (range, 1-3) superficial fissuring
ulcer in their
colectomy specimens (but without any other features of CD), as well as a control group of 18 patients (male-to-female ratio, 10/8; mean age, 41 years) with equally severe disease, but without fissuring
ulcers. Both groups were evaluated for a variety of clinical and pathologic features, such as clinical presentation, degree, extent, and duration of
colitis, and follow-up information, such as the development of
pouchitis, pouch fistulae, and any other features of CD. Overall, 81% of the study patients presented clinically with fulminant
colitis and underwent an emergent or urgent
colectomy, compared with only 41% of the control patients (P = 0.02). Nine (43%) study patients had active
serositis in their
colectomy specimens, whereas only 1 (6%) control patient had this finding (P = 0.002). However, no significant differences were noted in either the extent or severity of disease or the presence of active ("backwash")
ileitis, between the study and control groups. Upon follow-up (mean, 42 months; range, 4-121 months), the study patients with superficial fissuring
ulcers developed
pouchitis significantly more often (68% vs. 20%, P = 0.007) than the control group following an
ileal pouch-anal anastomosis (IPAA) procedure. One patient from each group developed an
anal fissure and another from each group developed an anastomotic
stricture. In addition, 1 study patient developed a pouch-
cutaneous fistula, and 1 control patient developed an
enterocutaneous fistula to a loop
ileostomy. Finally, 1 control patient ultimately had her pouch excised because of recurrent intractable
pouchitis. However, none of the other study or control patients developed any clinical or pathologic manifestations of CD. We conclude that superficial fissuring
ulcers may occur in patients with severe chronic active UC, particularly those who present with fulminant disease. Affected individuals should not be considered to have CD or "indeterminate"
colitis and should not be denied an IPAA procedure. Nevertheless, the presence of superficial fissuring-type
ulcers in patients with severe chronic active UC denotes a subgroup with a higher risk of
pouchitis following surgical resection.