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Inflammatory Bowel Inflammatory Bowel DiseaseDisease
Dr. Hagit Tulchinsky, Proctology Unit, Surgery B
Tel Aviv Sourasky Medical Center
EpidemiologyEpidemiology
Developed countries More common in Jewish population (3-5 folds),
whites Equal distribution between genders Bimodal age distribution: 15-35y, 50-70y
Etiology-1Etiology-1
UC and Crohn`s – separate entities ? 10-15% of IBD - Indeterminate colitis 10% - diagnosis is changed Relatives – more likely to have the same disease as
the proband Cluster within families
Etiology-2Etiology-2
Genetic predisposition + environmental factors (dietary intake)
Complex genetic disorder UC - less significant genetic contribution than in
Crohn`s d. Susceptibility locus, IBD 1, on chromosome 16 Molecular evidence of 2 forms of Crohn`s pANCA – in most UC patients (75%)
Etiology-3Etiology-3
Host – defective mucosal barrier function NSAID`s exacerbate IBD Cigarette smoking: protective in UC, aggressive
factor in Crohn`s d.
Etiology- SummaryEtiology- Summary
These diseases are due to aberrant host response to environmental antigens in genetically susceptible individuals
Pathology-UC-1Pathology-UC-1
From rectum proximally Confined to colon and rectum Disease limited to the mucosa Macroscopic appearance
congested serosa
contracted and shortened bowel edema of the mesentery pseudopolyps 10% backwash ileities
Microscopic appearance
Only the mucosa is affected Cancer and dysplasia
3-5% develop cancer
Increased risk if extensive disease for at least 8
years
Surgery if low grade dysplasia
Pathology-UC-2Pathology-UC-2
Pathology Pathology Crohn`s disease-1Crohn`s disease-1
May affect any part of the intestinal tract Usually affects the terminal ileum and cecum Small bowel alone – 1/3 Colon alone – 1/3 Perianal region or upper GI tract alone – less
common
Pathology Pathology Crohn`s disease-2Crohn`s disease-2
Macroscopic appearance Skip lesions
Segmental colitis
Stenosis of terminal ileum
Anal lesions in 75%
Wrapping of mesenteric fat
Thickened wall irregularly
Thickened mesentery
Pathology Pathology Crohn`s disease-3Crohn`s disease-3
Microscopic appearance Patchy distribution 2/3 – noncaseating granulomas, Transmural chronic inflammation, Serositis, fibrous adhesions Deep ulcers into the muscle layersCancer and dysplasia Increased risk in long standing disease
Pathology-SummeryPathology-Summery
Pathologic features – more usually seen in chronic stages of the disease
Cardinal feature of Crohn`s d. - patchiness The presence of small bowel disease should
exclude UC High or complex perianal fistula / anal ulceration
– more likely Crohn`s d. Crypt distortion – characteristic of UC Granulomas are less specific
Clinical findingsClinical findings
Diarrhea, mucous discharge Rectal bleeding- more UC Obstructive symptoms- more Crohn’s d. Anal/perianal d.- more Crohn’s d. Loss of body weight Anemia
Physical findingsPhysical findings
Reflect the severity of the disease Abdominal tenderness (left side) Abdominal distention Fever, tachycardia Proctitis- urgency, tenesmus, fecal incontinence
Extraintestinal manifestationsExtraintestinal manifestations
Peripheral arthritis, 15-20%, resolve after colectomy Ankylosing spondylitis Sacroiliitis Primary sclerosing cholangitis – more in UC, no
resolution post op
Surgery-UCSurgery-UC
20-45% eventually undergo surgery Indications – elective / emergency Pre op. management:
- Correct hypovolemia + electrolytes
- Correct anemia
- If on steroids – Hydrocortisone I.V.
- Counseling and education on the outcome
- Severe malnutrition – TPN
- Prepare as for colon surgery
Indications for elective surgeryIndications for elective surgeryUCUC
Intractability – most common Involvement of other organs Large bowel dysplasia/cancer
Indications for elective surgeryIndications for elective surgeryUCUC
Intractability Failure of medical therapy Chronic complications of the disease Debilitating symptoms Poor nutrition Impaired quality of life Anemia Hypoproteinemia Children- failure to growth Side effects
Indications for elective surgeryIndications for elective surgeryUCUC
Presence and risk of cancer When to consider prophylactic surgery/close
surveillance program? Extensive and long standing colitis Onset at childhood/teenage + generalized colitis +10 or more yrs of disease – 2% will develop cancer each year PSC Dysplasia
Indications for elective surgeryIndications for elective surgeryUCUC
Debilitating extra intestinal manifestations
May improve after surgery
Cutaneouos, peripheral arthicular, ocular, hematological,vascular
Ankylosing spondilitis and rheumatoid arthritis will not regress
PSC may progress to cirrhosis or cholangio ca. after surgery
Indications for emergency surgeryIndications for emergency surgeryUCUC
Fulminant colitis
Tachycardia, fever, WBC > 10,500, low albumin
First – aggressive conservative treatment
Failure – surgery
Goal – operate before colonic perforation
Toxic megacolon Pain, fever, toxicity, abdominal tenderness and distention,
transverse colon >7cm
Perforation, hemorrhage and obstruction
Choice of Operation-UCChoice of Operation-UC
Restorative proctocolectomy Treatment of choice if elective CI – Crohn`s, incompetent sphincter, cancer in distal rectum Proctectomy with continent ileostomy Brooke ileostomy, poor sphincter Proctectomy with Brooke ileostomy Colectomy and ileorectal anastomosis Rarely used today only if relative rectum sparing, young males
Normal anatomyNormal anatomy
ProctocolectomyProctocolectomy
Colectomy with ileorectal Colectomy with ileorectal anastomosisanastomosis
Choice of OperationChoice of Operation
Elective treatment of choice
Restorative proctocolectomy with ileal reservoir
The ileal pouch anal anastomosis
The pouch procedureThe pouch procedure
Removes all of the colon and rectum Preserves the anal canal Aim – to avoid permanent ileostomy The decision is up to the patient Information on the pros and cons
The pouch procedureThe pouch procedure
WHO IS ELIGIBLE ? Ulcerative colitis and not Crohn`s disease Patients who had no operation Patients who had a colectomy with ileostomy or
ileorectal anastomosis Good anal sphincter control
The pouch procedureThe pouch procedure TechniqueTechnique
Stage 1- The pouch operation
Abdomen opened Colon and rectum are freed Rectum is cut above the anal sphincter Small bowel and anus left in place
Abdominal incisionAbdominal incision
ProctocolectomyProctocolectomy
The pouch procedureThe pouch procedure TechniqueTechnique
Stage 1- The pouch operation
J pouch Pouch joined to the anus Protective loop ileostomy
ILEAL POUCH-ANAL ILEAL POUCH-ANAL ANASTOMOSISANASTOMOSIS
The pouch procedureThe pouch procedure TechniqueTechnique
Stage 2 – Closure of ileostomy
Relatively minor procedure Cut around the ileostomy Bowel closed The hole in the abdomen closed
The pouch procedureThe pouch procedure ResultsResults
Early complications Obstruction Infection
The pouch procedureThe pouch procedure ResultsResults
Late complications Obstruction Pouchitis Defecation problems Anal skin soreness Pouch fistula
The pouch procedureThe pouch procedure ResultsResults
Function Frequency Urgency Continence Anti diarrheal medications
The pouch procedureThe pouch procedure ResultsResults
Quality of life
90% - better
Failure
Up to 15%
SurgerySurgeryCrohn`s diseaseCrohn`s disease
Typical presenting symptoms: Abdominal pain, diarrhea, weight loss Reserved for patients whose quality of life is
significantly impaired despite appropriate medical therapy or after disease associated complications develop
The probability of undergoing surgery is 78-90% after 20 and 30 yrs, respectively
Elective / emergent indications
Indications for elective surgeryIndications for elective surgeryCrohn`s diseaseCrohn`s disease
Fistula ± abscess
The most common indication
Different types of fistula
Rarely heal with corticosteroids
6-MP will promote closure in 30-40%
Obstruction
Chronic/acute
Single/multiple sites of stricture
Indications for elective surgeryIndications for elective surgeryCrohn`s diseaseCrohn`s disease
Failed medical therapy
Incomplete response
Maintenance medications cannot be stopped
Significant side effects
Intra abdominal abscess/fistula Carcinoma Growth retardation
15-30% of children with Crohn`s
Op. is indicated only in the pre pubertal child
Indications for emergency surgeryIndications for emergency surgery Crohn`s disease Crohn`s disease
Fulminant colitis and Toxic megacolon
Acute flare and at least 2 of the following: Tachycardia >100 , fever >38.6, WBC > 10,500, albumin<3 Initial therapy –correct physiological deficits,
high dose steroids or immunosuppresants, bowel rest, antibiotics
Any worsening during the initial 48h - surgery Free perforation, massive hemorrhage, peritonitis, septic
shock – emergent op.
Indications for emergency surgeryIndications for emergency surgery Crohn`s disease Crohn`s disease
Perforation Most are sealedMassive bleeding Rare – 1% of patients
Principles of operative treatmentPrinciples of operative treatment Crohn`s disease Crohn`s disease
PALLIATIVE, CONSERVATISM
Minimal procedure with maximal effect Mechanical and antibiotic preparation I.V. Steroids Stop immunosuppressive therapy Correction of deficits Stoma marking
Operative optionsOperative options Crohn`s disease Crohn`s disease
Bypass
Rarely recommended – high recurrence rate and malignancy risk
Resection
Macroscopic healthy margins
Anastomosis
Stapled or handsewn
Same principles as for any anastomosis
Operative optionsOperative options Crohn`s disease Crohn`s disease
Stricturoplasty - Small bowel strictures, fibrotic recurrence at
ileocolic or ileoractal anastomosis
- Not for colonic narrowing
- Indications and contra indications
- Technique
STRICTUROPLASTY STRICTUROPLASTY (HEINEKE-MIKULICZ)(HEINEKE-MIKULICZ)
STRICTUROPLASTY STRICTUROPLASTY (FINNEY)(FINNEY)
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