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HYPOSPLENISM IN INFLAMMATORY BOWEL DISEASE
B. S. Rameh, F. M. Stevens and C. F. McCarthy
University Department of Medicine, Regional Hospital, Galway.
Summary
S PLENIC function was assessed by counting the percentage of pitted erythrocytes in twenty
patients with ulcerative colitis and eighteen pat- ients with Crohn's disease.
This method is a sensitive one of detecting hyposplenism. Ten patients with ulcerative colitis and six patients with Crohn's disease had pitted erythrocyte counts above the level found in normo- splenic individuals (3.4%). The levels were less than those in a group of patients who had had splenectomy. Age and sex had no effect on pit counts. Although disease activity and extent did not affect pit counts, it tends to be higher in pat- ients with more extensive and more active disease.
Introduction
Since 1974 there have been several reports of hyposplenism in patients with inflammatory bowel disease (IBD). It is more common in ulcerative colitis (UC) than in Crohn's disease (CD) 1,2,3.
Its significance remains uncertain, but has been implicated in post-operative problems of dissemin- ated intravascular coagulation1, 3.
There is a trend in patients with ulcerative colitis who are hyposplenic to have-more active and extensive disease 3. This association of hypo- splenism with activity and extent of CD is less definite.
The method used in this study to assess hypo- splenism (counting the percentage of pitted ery- throcytes) has been applied to other diseases including coeliac disease',L It correlates with other methods used for measuring splenic function'. Splenic function in IBD has not previously been assessed by this method.
Patients and Methods
Thirty-five healthy volunteers, 27 splenectomised subjects, 20 patients with UC and 18 patients with with CD were included.
The diagnosis of UC is based upon endoscopic, histological and radiological findings. Extent of the disease was designated either local (proctitis and proctosigmoiditis) or total colitis. Activity of the disease was assessed by the criteria of UC disease activity 6.
The pattern of bowel involvement in CD includes, ileal disease alone and ileo colonic disease. Diag- nosis of CD was based upon clinical features, radiological, endoscopic and histological findings. Disease activity was assessed by the criteria of a simplified CD activity indexL
Pitted erythrocyte counts were performed by the method of Pearson et aP and results were expres- sed as the percentage of 1000 erythrocytes con- taining one or more pits.
All counts were carried out on coded specimens so that observer (BR) was unaware of the clinical status of the subjects. Blood samples were drawn for full blood count including (platelet counts), ESR, red cell folate and for total proteins and albumen.
Statisti�9 method
Results were statistically analysed by using the student's 't' test applying Bonferroni method 9 and by Chi square (X ~) using Yates correction 1~
Results
In the normal controls (n=35) the mean age: was 37.6 years, and eighteen were females. The mean of pit counts was 1.74% with a range of 0.4% - 3.2%.
In the group of patients with UC (mean age = 46.5 years), nine were females. The range of pit counts was 0.4- 9.2% with a mean of 3.9%. Nine of the patients with CD were females. The, mean age of the total group was 32.4 years, range of pit counts was 0.8-7.4% with a mean of 2.96%. The age of the studied groups was similar. Sig- nificantly higher pit counts were found in the splenectomised subjects and in the group of pat- ients with inflammatory bowel disease (UC and CD), than in the normal group (P<0.001), figure 1.
Hyposplenism was diagnosed if the pitted ery- throcyte counts were higher than 3.4%. Ten of the
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Vol. 157 No. 1
patients with UC and six with CD had counts higher than this figure. Age and sex did not affect the pit counts, although disease activity and extent did not affect the pit counts, tt tends to be. higher in the group of patients with more active and extensive disease.
Discussion
Pitted erythrocytes are morphologically distinct from other red cell inclusions found after sple,nec- tomy, e.g. HoweI-Jolly bodies. Counting these cells is more, useful than counting the other inclusions for the purpose of the diagnosis of hyposplenism 11. Pitted erythrocyte counts are accurate and quanti- tative assessments of hyposplenism in coeliac disease ~'. They have, been found to correlate well with both clearance rates of labelled, heat-damaged erythrocytes and splenic size computed from scin- tiscans in the assessment of splenic function of coeliac patie, ntst The technique has the advantage ol being simple, non-invasive, free from exposure to radiation and applicable to all subjects.
Hyposplenism associated with inflammatory bowel disease is more common with ulcerative colitis than with CD 1,:~. In the group of patients with IBD, ten of twenty patients with ulcerative colitis and six of eighteen patients with Crohn's disease had higher pit counts than the measurements in normosplenic individuals.
In ulcerative colitis, although statistically disease activity and extent did not affect the pit count, higher counts (>3 .4%) we,re found in four of five patients with active, disease, and in seven of ten patients with total colitis.
In the case of CD higher counts of pitted ery- throcytes were, found in three of five patients with active disease,, and mainly in patients with ileo- colonic involvement. Only one, patients of ten with ileal disease had a higher count. These results are in keeping with series using other methods of splenic function asse,ssment 1,=,~.
There is a trend in patients with ulcerative colitis who are hyposplenic to have more active and ex-
Hyposptenism in inflammatory bowel disease 9
tensive disease, this association with Crohn's dis- ease is less definite.
Severe hyposplenisem is potentially a lethal condition 1~. Hyposplenism in inflammatory bowel disease associated with increased susceptibil i ty to post-operative complications (e.g. septicaemia and DIC). Therefore., it seems important to detect hypo- splenism before, operation and alert the surgeon to the possibility of post-operative complications. Counting the, pitted erythrocytes is a simple, method of doing this.
We would like to thank Dr. T. O'Gorman for giving us access= to his patients and Mary Bourke, Gastroenterology Laboratory, Regional Hospital, Galway.
References
1. Ryan, F. P., Smart, C. D., Holdsworth, C. D., Preston, F. E. Hyposplenism in inflammatory bowel disease. Gut 1978: 19, 50-55.
2. Jewell, D. P., Berney, J. J., Pettit, J. E. Splenic phago. cytic function in patients with inflammatory bowel disease. Path. 1 g81: 13, 717-723.
3. Palmer, K. R., Sheriff, S., HOldS, worth, C. F., Ryan, F. P. Further experience of hyposplenism in inflammatory bowel d!isease. Quart. J. Meal. 1981: 200, 464-471.
4. Corazza, G. R., Bullen, A. W., Halt, R., Robinson, P. J., Losowsky, M. S. Simple method ~ of assessing splenic function in coeliac disease. Clin. Sci. 1981: 60, 109-113,
5. O'Grady, J. G. Splenic function in coeliac d'isease. MD Thesis, University College, Galway. 1983.
6. Talstad, I., Gjone, E. The disease activity of ulcerative colitis and Crohn's disease. Scand'. J. Gastroenterol. 1976:11, 403-408.
7. Harvey, It. F., Brad,shaw, J. M. A simple index of Crohn's Disease activity. Lancet 1980: 1, 514.
8. Pearson, H. A., Johnston, D., Smith, K. A., Toulou,kien, R. J. The born-again spleen : return of splenic function after splenectomy for trauma. N. Engl. J. Meal. 1978: 298, 1389-1392.
9. K-Godfrey. Comp,aring the means of several groups. N. Engl. J. Med. 1985: 313, 1450-1456.
10. Swinscow, T. D. V. Statistics at Square One. Eighth edition. 1983.
11. Koyama, S., Kihira, H., Aoki, S., Ohnishi, H; Post- splenectomy vacuole : a new erythrocyte inclusion body. Mie. Med. J. 19(~2: 11, 425-437.
12. Bisno, A. L., Freeman, J. C. The syndrome of asplenia pneumococcal sepsis and disseminated intravascular coagulation. Ann. Intern. Med. 1970: 71, 389.
