Peri-anal disease and IBD in Adolescence

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Peri-anal disease and IBD in Adolescence

• Bruce D George
• John Radcliffe Hospital
• Oxford

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Aims of Management of Crohns disease in
adolescence

• Control intestinal symptoms
• Optimise growth
• impaired at time of diagnosis in 88
• Facilitate normal social development

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Indications for Surgery in Crohns disease

• Emergency
• perforation
• bleeding
• acute colitis
• Elective
• obstruction
• fistula
• chronic ill health/failure of medical therapy

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In adolescence

• Also delayed growth

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Principles of surgery in adolescence

• Similar to adults
• operate as soon as there is an indication
• play safe
• minimal resection
• But also
• earlier surgery to facilitate growth and to avoid
  steroids

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Difficult problems

• Aggressive disease
• Early recurrence
• Psychological
• chronic ill health
• body image
• height, weight
• sexual development
• stoma

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Indications for surgery in Ulcerative Colitis

• Acute colitis
• Failure of medical therapy
• chronic disease
• recurrent acute attacks
• Dysplasia
• Impaired growth

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Factors to consider

• Overall fitness steroids,
  co-morbidity
• Colon certainty of
  diagnosis
• Psychology acceptability of
  stoma
• Sphincters manometry, U/S
• Nerves and tubes pelvic dissection

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Surgical options in ulcerative colitis

• Proctocolectomy and end ileostomy
• Proctocolectomy and ileal pouch reconstruction
• Colectomy and ileostomy (rectal stump)
• Colectomy and ileorectal anastomosis

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UC in Adolescence

• Consider colectomy and ileorectal in teens
• Completion proctectomy and pouch later

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Anal Crohns disease

• Anal Crohns disease
• 20-80 of patients with Crohns get perianal
  disease
• Rectal gt colonic gt ileocaecal gt small bowel

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Clinical features

• Primary
• Fissures
• Skin tags
• Ulcers

• Secondary
• Abscess/fistula
• Strictures
• Vaginal fistula
• (malignancy)

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Variable natural history

• Benign
• fissures, tags
• Variable
• fistulae, strictures
• Aggressive
• cavitating ulcers, sepsis

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Assessment of Anal Crohns disease

• General
• Large bowel
• colonoscopy
• Small bowel
• small bowel enema
• Anus
• inspection
• EUA
• ultrasound, MRI

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Aims of Treatment of Anal Crohns

• Minimise symptoms
• Prevent complication
• sepsis
• incontinence
• unhealed wounds
• stenosis

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Treatment Options

• Do nothing
• Diet
• elemental, TPN
• Medical
• antibiotics, immunosuppressants, anti-TNF alpha
• Surgery
• drain sepsis, local procedures, distant
  resection,
• defunction, proctocolectomy

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Treatment of Specific Lesions

• Skin tags leave alone
• Haemorrhoids surgery
  contraindicated
• Fissures
• if painless leave alone
• if painful GTN,
  Botulinum

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• Low Fistula
• may heal spontaneously
• if no rectal inflammation lay open

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• High fistula
• unlikely to heal
• ensure sepsis drained
• anti-TNF alpha
• ?fibrin glue
• defunction
• proctocolectomy

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• Anal Ulcers
• poor prognosis
• maximal medical therapy
• defunction
• proctocolectomy

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Summary of Anal Crohns Disease

• Thorough assessment
• Tailoring treatment to individual
• Symptom control
• Prevention of complications
• Accept defeat