Crohn ' s disease be diagnosed at laparotomy ?

The typical macroscopic features of Crohn's disease have been well described and are widely regarded as sufficient to diagnose the disease at laparotomy. We report six patients undergoing laparotomy for symptomatic Crohn's disease, shown radiologically, who were found to have macroscopically normal small bowel despite careful examination of the bowel by an experienced surgeon. In four cases resection was deferred, but all subsequently deteriorated and required further surgery. Minor abnormalities found by balloon examination of the terminal ileum prompted resection in two further patients. Histology showed an unusually superficial distribution of inflammation, which could explain the negative findings at laparotomy. We conclude that normal laparotomy findings alone do not exclude a diagnosis of clinically important small bowel Crohn's disease. Crohn's disease should be considered in patients with persisting symptoms after negative laparotomy. The macroscopic features ofsmall bowel Crohn's disease have been well described. "-'° Recognition of these is said to be a reliable aid to diagnosis at laparotomy when previous investigation has failed to establish the diagnosis.6 The descriptions in published reports relate to well established disease, and we can find no discussion of the accuracy of laparotomy assessment in cases where the operative findings are less clear cut. While it is not uncommon to discover Crohn's disease unexpectedly at laparotomy, the opposite clinical problem, where apparently normal bowel is found at laparotomy in patients with symptoms and radiological findings highly suggestive of Crohn's disease, is unusual and presents considerable management difficulties. We have encountered six such patients out of 175 patients undergoing laparotomy for small bowel Crohn's disease over 18 years. The laparotomy assessment in each case was performed by one of the authors (LEH). We can find no guidance in publications on how to deal with this problem.