Inflammatory Bowel Disease

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Inflammatory Bowel Disease

• Dr. Hagit Tulchinsky,
• Proctology Unit, Surgery B
• Tel Aviv Sourasky Medical Center

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Epidemiology

• Developed countries
• More common in Jewish population (3-5 folds),
  whites
• Equal distribution between genders
• Bimodal age distribution 15-35y, 50-70y

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Etiology-1

• UC and Crohns 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

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Etiology-2

• Genetic predisposition environmental factors
  (dietary intake)
• Complex genetic disorder
• UC - less significant genetic contribution than
  in Crohns d.
• Susceptibility locus, IBD 1, on chromosome 16
• Molecular evidence of 2 forms of Crohns
• pANCA in most UC patients (75)

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Etiology-3

• Host defective mucosal barrier function
• NSAIDs exacerbate IBD
• Cigarette smoking protective in UC, aggressive
  factor in Crohns d.

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Etiology- Summary

• These diseases are due to aberrant host
  response to environmental antigens in genetically
  susceptible individuals

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Pathology-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

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Pathology-UC-2

• 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

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Pathology Crohns 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

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Pathology Crohns 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

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Pathology Crohns disease-3

• Microscopic appearance
• Patchy distribution
• 2/3 noncaseating granulomas,
• Transmural chronic inflammation,
• Serositis, fibrous adhesions
• Deep ulcers into the muscle layers
• Cancer and dysplasia
• Increased risk in long standing disease

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Pathology-Summery

• Pathologic features more usually seen in
  chronic stages of the disease
• Cardinal feature of Crohns d. - patchiness
• The presence of small bowel disease should
  exclude UC
• High or complex perianal fistula / anal
  ulceration more likely Crohns d.
• Crypt distortion characteristic of UC
• Granulomas are less specific

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Clinical findings

• Diarrhea, mucous discharge
• Rectal bleeding- more UC
• Obstructive symptoms- more Crohns d.
• Anal/perianal d.- more Crohns d.
• Loss of body weight
• Anemia

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Physical findings

• Reflect the severity of the disease
• Abdominal tenderness (left side)
• Abdominal distention
• Fever, tachycardia
• Proctitis- urgency, tenesmus, fecal incontinence

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Extraintestinal manifestations

• Peripheral arthritis, 15-20, resolve after
  colectomy
• Ankylosing spondylitis
• Sacroiliitis
• Primary sclerosing cholangitis more in UC, no
  resolution post op

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Surgery-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

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Indications for elective surgeryUC

• Intractability most common
• Involvement of other organs
• Large bowel dysplasia/cancer

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Indications for elective surgeryUC

• 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

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Indications for elective surgeryUC

• 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

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Indications for elective surgeryUC

• 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

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Indications for emergency surgeryUC

• Fulminant colitis
• Tachycardia, fever, WBC gt 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 gt7cm
• Perforation, hemorrhage and obstruction

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Choice of Operation-UC

• Restorative proctocolectomy
• Treatment of choice if elective
• CI Crohns, 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

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Normal anatomy
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Proctocolectomy
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Colectomy with ileorectal anastomosis
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Choice of Operation

• Elective treatment of choice
• Restorative proctocolectomy with ileal
  reservoir
• The ileal pouch anal anastomosis

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The 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

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The pouch procedure

• WHO IS ELIGIBLE ?
• Ulcerative colitis and not Crohns disease
• Patients who had no operation
• Patients who had a colectomy with ileostomy or
  ileorectal anastomosis
• Good anal sphincter control

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The pouch procedure Technique

• 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

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Abdominal incision
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Proctocolectomy
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The pouch procedure Technique

• Stage 1- The pouch operation
• J pouch
• Pouch joined to the anus
• Protective loop ileostomy

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ILEAL POUCH-ANAL ANASTOMOSIS
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The pouch procedure Technique

• Stage 2 Closure of ileostomy
• Relatively minor procedure
• Cut around the ileostomy
• Bowel closed
• The hole in the abdomen closed

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The pouch procedure Results

• Early complications
• Obstruction
• Infection

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The pouch procedure Results

• Late complications
• Obstruction
• Pouchitis
• Defecation problems
• Anal skin soreness
• Pouch fistula

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The pouch procedure Results

• Function
• Frequency
• Urgency
• Continence
• Anti diarrheal medications

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The pouch procedure Results

• Quality of life
• 90 - better
• Failure
• Up to 15

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SurgeryCrohns 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

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Indications for elective surgeryCrohns 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

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Indications for elective surgeryCrohns 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 Crohns
• Op. is indicated only in the pre pubertal
  child

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Indications for emergency surgery Crohns
disease

• Fulminant colitis and Toxic megacolon
• Acute flare and at least 2 of the following
• Tachycardia gt100 , fever gt38.6, WBC gt 10,500,
  albuminlt3
• 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.

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Indications for emergency surgery Crohns
disease

• Perforation
• Most are sealed
• Massive bleeding
• Rare 1 of patients

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Principles of operative treatment Crohns
disease

• PALLIATIVE, CONSERVATISM
• Minimal procedure with maximal effect
• Mechanical and antibiotic preparation
• I.V. Steroids
• Stop immunosuppressive therapy
• Correction of deficits
• Stoma marking

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Operative options Crohns disease

• Bypass
• Rarely recommended high recurrence rate and
  malignancy risk
• Resection
• Macroscopic healthy margins
• Anastomosis
• Stapled or handsewn
• Same principles as for any anastomosis

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Operative options Crohns disease

• Stricturoplasty
• - Small bowel strictures, fibrotic recurrence
  at
• ileocolic or ileoractal anastomosis
• - Not for colonic narrowing
• - Indications and contra indications
• - Technique

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STRICTUROPLASTY (HEINEKE-MIKULICZ)
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STRICTUROPLASTY (FINNEY)
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Thank You