52
Vol. 66, No. 4 2015
Northeast Florida Medicine
DCMS online
. org
Inflammatory Bowel Disease
obstruction.These have been treatedwith gastrojejunostomy
and duodenojejunostomy. However, a bypass procedure
carries significant long term complications. Therefore,
Heineke-Mikulicz type strictureplasty is preferred if feasible
surgically. Colonic strictures can be resected. Benign colonic
strictures can also be treated with a self-expanding stent.
Abscess formation:
A patient presenting with sepsis secondary to peritonitis
needs to go to the operating roomfor definitive care.However,
most of the time that is not the case and the patient presents
with phlegmon or contained perforation. These should be
drained either under CT or ultrasound guidance. Many will
resolve with additional antibiotics, nutrition supplement and
hydration. If these measures fail, these patients will go for
surgical resection. Resection of the diseased segment is the
treatment of choice. If the severe acute inflammation with
phlegmon is close to major vessels, it should be treated by
exclusion of the diseased segment. These should be followed
by definitive resection, as the rate of malignancy in the by-
passed segment is higher. If the bypassed segment is long,
one should consider bringing out the proximal end of the
bypassed segment as mucous fistula. If the abscess involves
multiple loops, it will need to have surgical intervention.
The key is to spare and save the length of the bowel. If the
abscess is more extensive, it is better to divert and let the
infection and sepsis clear and save the length of the bowel.
In some patients an abscess eroding to the psoas region can
result in compression of the ureter. This will cause hydro-
nephrosis. It will require resection for definitive treatment.
Fistula:
Enteroenteric Fistula:
Even though 30 percent of Crohn’s patients get fistula,
this in itself usually does not require surgery.
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Enteroenteric
fistula may remain asymptomatic and can be found on lap-
arotomy. However, a communication between proximal to
the distal loop can cause diarrhea, malabsorption. In these
cases, a physician encounters fistulous communication be-
tween distal ileum to proximal jejunum needing resection.
Some patients will develop enterocutaneous fistula at the
abdominal scar from previous surgery or a site of previous
abscess drainage. Most of the time the drainage is small and
patients are reluctant to go for surgery. These will need to
be excised on an individual basis.
Genitourinary tract fistula:
Enterovesical and enterovaginal fistulae will need to be
addressed surgically by resection of the diseased segment.
Enterovesical fistula can lead to pyelonephritis, further af-
fecting the kidneys. Enterovaginal fistula will affect personal
hygiene and can cause severe perineal skin excoriation. The
low lying rectovaginal fistula or the more-commonly found
anointroitus fistula can be approached by creating a transanal
flap over the fistula and applying a bioplug, available from
different manufacturers, in the fistula tract. The procedure
can be repeated if the initial procedure fails. Also, bioplugs
have been used to close these fistulae. In difficult cases,
such as in mid and low rectovaginal fistula, laparoscopically
omental flap reconstruction of the rectovaginal space can
be a decisive therapy. In treating these, a physician must
exclude other common etiologies of diverticular disease, as
well as colonic and gynecologic malignancy.
Perianal and Perineal fistula:
Fistulas in the perianal and perineal area are common in
Crohn’s disease if the rectum is involved. A combination
of rectal disease of the Crohn’s with anal fistula invariably
leads to proctocolectomy. Spontaneous healing of fistulae
has occured after resection of the intestine, even when the
disease does not involve the colon or rectum. Many of these
cases progress from perianal abscesses into fistula. These
must be drained. Superficial fistulas may be unroofed to
avoid abscess formation.
Deep fistulas cross the sphincter. The fistulotomy may
result in incontinence. Therefore, these can be treated with
draining setons loosely applied in the tract. These prevent
abscess formation, but rarely heal.
Bioabsorbable xenograft anal plugs fromSurgisis andGore
have beenused to plug the tract and the fibrotic reaction closes
the fistula. When all of these fail, a rectal advancement flap
may be used to close the internal opening of the fistula. In
some cases, one may have to divert the fecal stream either via
temporary or permanent colostomy after proctocolectomy.
Perforation:
This is a rare event. Besides the disease itself, a distal ob-
struction or transmural ulcer in toxic colitis can also result
in perforation. Some will heal by adhesions to the adjacent
structures. When a free intraperitoneal perforation occurs,
the general condition of the patient will change suddenly.
Most of these patients with free intraperitoneal perforation
will need to go to the operating room.These require resection
and peritoneal lavage.