Rob Padwick MRCS27th July 2011

CHALLENGES IN SURGICAL

MANAGEMENT OF INFLAMMATORY

BOWEL DISEASE

Aims

Management of severe (fulminant) colitis

Crohn’s disease

Prevalence 0.15% Unknown Aetiology;

Familial/Genetic Smoking REDUCES risk Immunological response

Affects Large Bowel mucosa ONLY Extra GI manifestations – eyes,

joints, skin, liver and biliary tree

ULCERATIVE COLITIS (UC)

ACUTE COMPLICATIONS OF UC

1. Acute severe (fulminating) colitis

2. Toxic megacolon

3. Perforation / Abscess

4. Bleeding

LONG-TERM COMPLICATIONS OF UC

1. Strictures

2. Recurrent Acute Attacks

3. Steroid Dependence

4. Colorectal Cancer

ACUTE SEVERE ULCERATIVE COLITIS

History and examination

• Bloody diarrhoea with mucus

• Urgency, abdo cramps

• Tachycardia, dehydration, pyrexia, peritonism,

• PR blood / mucus

ACUTE SEVERE ULCERATIVE COLITIS

Investigations• U&E

• FBC - WCC, Hb

• LFT’s – Albumin

• INR

• CRP

• ABG

• AXR, Erect CxR, CT

• Stool culture

• Unprepared FOS with minimal insufflation

- Confluent ulceration, erythema, contact bleeding

ACUTE SEVERE ULCERATIVE COLITIS

TREATMENT

1. Resuscitation – give blood, correct coagulopathy

correct metabolic derangement

2. Medical

Steroids• IV Hydrocortisone 100mg qds• 5 days if responding then oral steroids• Prednisolone 40mg o.d.

ACUTE SEVERE ULCERATIVE COLITIS

TREATMENT

2. Medical (cont.)

Steroids

Azathioprine

• Purine analogue immunosuppressant

• Steroid sparing

ACUTE SEVERE ULCERATIVE COLITIS

TREATMENT

2. Medical (cont.)

Steroids

Azathioprine

5-ASA

• Little / no role in acute setting

ACUTE SEVERE ULCERATIVE COLITIS

TREATMENT

2. Medical (cont.)Steroids

AzathioprineSalicylatesOther• PPI• Antibiotics• DVT prophylaxis

ACUTE SEVERE ULCERATIVE COLITIS

TREATMENT

2. Medical (cont.)

Cyclosporin

• Immunosuppressant

• Steroid failures at 5 days

• Remission in 50%

• Reduces need for emergency surgery

MEDICAL MANAGEMENT SUMMARY

The Oxford criteria the five day rule Truelove & Jewell 1974

Azathioprine maintenance of remission

Cyclosporin induction of remission McCormack G

2002

MEDICAL MANAGEMENT CHALLENGES

Uncertain end points

Masked sepsis

Late relapse

ACUTE FULMINATING COLITIS (UC)

TREATMENT

3. Surgical management

• Failure of medical at 5 days (25-50%)

• Toxic megacolon

• Perforation

• Bleeding

OPERATION

1. Sub-total colectomy

• Procedure of choice in the ill patient

• Preserve rectal stump

• Potential for Ileoanal pouch later

(IPAA)

2. Alternative operations

• Panproctocolectomy and end ileostomy

Postoperative management

• Wean steroids

• Monitor stump (e.g.proctitis)

• Monitor/treat sepsis

• Counseling via Multi-Disciplinary Team

TOXIC MEGACOLON

• ~45% mortality

• Surgery

• Non-resolution

• Impending or active perforation

PERFORATION

• More common in UC than Crohn’s

• Greatest risk is with first episode

• Especially splenic flexure, sigmoid colon

• Beware lack of signs!

HAEMORRHAGE

• Massive bleeding unusual

• 0-10%

• Colectomy is surgical procedure of choice

Risk increases with duration of disease; 2% at 10 years 8% at 20 years 18% at 30 years (Eaden et al 2001) Higher in severe colitis – 19x general population (Chambers

et al 2005) Colonoscopic Surveillance;

Colonoscopy at 10 years after diagnosis Follow-up according to risk stratification (NICE 2011) Dysplasia or malignancy on biopsy – proceed to total

colectomy

UC AND COLORECTAL CANCER

Crohn’s disease

Crohn’s disease

•Described in 1932 by Burrill Bernard Crohn

•Prevalence 0.07%

•Can affect the WHOLE GI TRACT

•Ileocaecal region ~50%

•15-40 years old

•Extra GI Manifestations – Eyes, Skin, Joints, Liver

Aetiology

•Largely unknown

•2-4x as common in smokers

•Genes – Chromosomes 3, 7, 12, HLA B27

•Family history

•Infective agents – Measles, Mumps, TB

Pathological features

•Transmural inflammation

•Fissures

•Non-caseating granulomas

•Skip lesions

Clinical features

•Diarrhoea

•Crampy Abdominal pain

•Weight loss

•Fever

•Perianal sepsis

•PR Bleeding

ACUTE COMPLICATIONS ININTESTINAL CROHN’S DISEASE

Investigation

• Haematology, biochemistry

• AXR, CxR

• Stool Culture

• Contrast study / CT

• MRI enteroclysis

1. Aims

• Palliate symptoms

• Control infection

• Correct nutrition

There is NO CURE !

TREATMENT

1. Medical

• Salicylates

• Azathioprine

• Steroids

• Biological agents (e.g. infliximab)

2 Surgical

TREATMENT

• Required in 75% of cases

• Indications;

• Failed medical treatment

• Stricture / Obstruction

• Abscess

• Fistulae

• Bleeding

SURGERY IN INTESTINALCROHN’S DISEASE

1. Stricturoplasty

• Avoids resection

• All strictures < 2cm

2. Limited bowel resection

SURGERY IN INTESTINALCROHN’S DISEASE

PERIANAL DISEASE

GENERAL

• > 50%

• Fissures

• Abscess

• Fistulae

• May be multiple and complex

PERIANAL DISEASE

FISTULAE

• Control sepsis

• Define and eradicate tracts

• Preserve sphincter function

Vagina Anus

CROHN’S AND COLORECTAL CANCER

•2-3x increased risk of colorectal cancer in

Crohn’s Disease (Bernstein et al 2001)

•Standard resection as opposed to total

colectomy

A 25 year old man presented with several months history of intermittent colicky abdominal pain. He noted some looseness of bowel movements during the past 6 months. He has lost about 1 stone in weight. Physical examination revealed a thin and young man. His temperature was normal. There was fullness in the RIF. Bowel sounds appeared to be hyperactive. PR examination was normal.

Na: 129 Hb: 13.1K: 2.9 WCC: 16Urea: 15 Platelet: 600

Creatinine: 250 CRP: 200a) State the likely diagnosis (1)

Acute Terminal Ileal Crohn’s Disease

b) Describe the obvious pathological feature of this disease shown in the picture above? (1 mark)Fat wrappingc) What are the radiological features of this disease? (2 marks)Any two of; Cobblestoning, pseudopolyps, skip lesions, stricturing, pseudodiverticulaed) What are the appropriate medical therapy for this disease (2 marks)Any two of; Salicylates, azathioprine, steroids, biologicals (e.g. infliximab)e) What are the indications for surgical intervention? (2 marks)Any two of; Failed Medical Therapy, Sricturing, Obstruction, Abscess, Fistulae, Bleedinge) What is Infliximab? (1 mark) Biological Agent - Anti-TNFa

Air under the diaphragm

Wrigler’s Sign