More than three out of four patients with Crohn's disease will require surgery within the first 20 years of the onset of initial symptoms. Abscess and fissure formation is seen in approximately 30 percent. Abscesses can be characterized as intraperitoneal, retroperitoneal, interloop, or intramesenteric. Ihese patients present with abdominal pain and tenderness typical of their underlying disease but may also have fever spikes and a palpable mass. Patients with retroperitoneal abscesses may present with hip or back pain and difficulty ambulating. Liver abscesses have also been reported in patients with Crohn's disease.

Fistulas are the result of extension of intestinal fissures noted in patients with Crohn's disease into adjacent structures. Ihe most common sites are between the ileum and the sigmoid colon, the cecum, another ileal segment, or the skin. Internal fistulas should be suspected when there are changes in the patient's symptom complex, including bowel movement frequency, amount of pain, or weight loss. Enterovesical fistulas are rare complications of Crohn's disease.

Obstruction is the result of both stricture formation due to the inflammatory process and of edema of the bowel wall. Ihe distal small bowel is the most common site of obstruction. Symptoms include crampy abdominal pain, distention, nausea, and bloating.

Perianal complications are seen in one-third of patients with Crohn's disease and include perianal or ischiorectal abscesses, fissures, fistulas, rectovaginal fistulas, and rectal prolapse. Ihese are more commonly seen in patients with colonic involvement.

While gastrointestinal bleeding is common in patients with Crohn's disease, only 1.3 percent of patients develop life-threatening hemorrhage. 5 In patients with Crohn's disease, bleeding is the result of erosion into a vessel in the bowel wall. Ioxic megacolon occurs in 6 percent of all cases of Crohn's disease and is associated with massive gastrointestinal bleeding in over half the cases. Fifty percent of all cases of toxic megacolon occur in patients with Crohn's disease. Free perforation, however, rarely occurs.

When bowel symptoms are present, malnutrition, malabsorption, hypocalcemia, and vitamin deficiency can be severe. In addition to the complications of the disease itself are complications associated with the treatment of the disease with sulfasalazine, steroids, immunosuppressive agents, and antibiotics.

Ihe incidence of malignant neoplasm of the GI tract is three times higher in patients with Crohn's disease than for the general population.

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