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Vol. 66, No. 4 2015
Northeast Florida Medicine
DCMS online
. org
Inflammatory Bowel Disease
Introduction
Crohn’s disease is a lifelong disease affecting the entire
GI tract. The symptoms wax and wane. Medical therapy
remains the treatment of choice. Complications, side ef-
fects of the disease, and failure of the medical treatment in
a symptomatic patient leads to surgical intervention. All
the treatment modalities treat the current acute symptoms
without curing the disease. Even with ever-evolving, new
treatment options, 70 percent of these patients will need
some type of surgery over the 10, 20 and 30 year period.
1
Additionally, 30 to 70 percent will require some type of
re-operation.
1
Approximately 85 percent of these patients
will have disease recurrence within one year.
2
Therefore, at
any surgical intervention a physicianmust conserve intestine
as much as possible. Aggressive medical treatment helps in
these post-op patients to avoid repeat surgery. One of the
main goals of medical treatment is to avoid and prevent
surgery. From the patient perspective, it is important to treat
urgently an imminent complication, rather than wait for
fistula, abscess or perforation to happen. The complication
rate from surgery after the disease is allowed to progress
escalates to almost 49 percent in these patients, compared
to 12 percent in the general population.
3
The serious con-
sideration for surgery in these patients at an appropriate
time will reduce the symptoms and complications, while
improving the quality of life.
Distribution of disease:
4
1. Ileocolic area . . . . . . . . . . 55 percent
2. Colon involvement . . . . . . . 19-51 percent
3. Jejunoileal disease . . . . . . . .10-20 percent
4. Anal and Perianal involvement . . . 4-80 percent
5
5. Duodenal Crohn’s . . . . . . . . 1- 2 percent
Indications for surgery:
Obstruction is the most common complication. Chronic
inflammation of the intestine results in fibrotic changes.
These result in strictures, causing obstruction.
Crohn’s disease can cause abscess formation. This can be
intraperitoneal, intramesenteric or retroperitoneal. The ab-
scess can be present in betweenmany loops of bowel. Patients
with Crohn’s disease are also prone to get fistula formation.
Fistulous communication in Crohn’s disease is known to
occur as internal or external. External are enterocutaneous
and perianal. Internal are enterovesical, enterovaginal and
enteroenteic and rarely impact other organs.
Diseased segments of intestine can result in adhesions
and inflammation leading to peroration. Transmural ulcers
and toxic colitis can result in perforation, as well. Less com-
monly, patients can have hemorrhage. This is a sudden event
resulting from erosion into mucosal or submucosal vessels.
Colon involvement can present in different forms. Car-
cinoma can start in polyp or from dysplasia of mucosa in
the colon. Risk increases after about 10 years of presence
of disease.
6
Toxic megacolon occurs secondary to severe
inflammation. Carcinoma of the small intestine, however,
is much less common.
Other extra-intestinal manifestations can be seen present-
ing as peptic ulcers, gallstones, Renal stones, hydronephrosis
and dermal manifestations. Growth retardation can also be
seen in the pediatric population. After adequate medical
therapy and proper nutrition, if there is growth retardation,
surgery should be considered and performed prior to closure
of epiphyses.
Treatment of surgical complications:
Pre-op Preparation:
If it is not an emergency and it is an elective or semi elec-
tive procedure, the patient should be medically optimized.
The following factors tremendously aid in the recovery of a
Crohn’s patient from surgery.The patient should be properly
hydrated. Electrolytes, hemoglobin and coagulation factors
should be corrected as much as possible. Nutritional status
shouldbe addressed inpatients who are severelymalnourished
Surgical Management of Crohn’s Disease
By Anand S. Gupta, MD
Address correspondence to:
Anand S. Gupta, MD
University Clinic
2535 University Boulevard West
Jacksonville, FL 32217