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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.

10

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.