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Northeast Florida Medicine
Vol. 66, No. 4 2015
53
Inflammatory Bowel Disease
Hemorrhage:
This is a rather uncommon event. Usually there are mini-
mally bloody stools, but hematochezia is not severe enough to
require surgical intervention or transfusion. However, some
chronic bleeding can cause persistent anemia. Significant
hemorrhage may be difficult to diagnose. Physicians need to
use bleeding scans, angiography and endoscopic procedures
to try to localize the site of bleeding. Unfortunately these
techniques are often unable to find the exact locations of
bleeding. Sometimes a physician has to resort to intraop-
erative enteroscopy or colonoscopy to ascertain the site of
bleeding, with a surgeon helping to advance the scope.
Carcinoma:
Crohn’s disease is a precancerous disease and the patient
will have a 4-20 times higher chance of developing cancer
in the affected portion of the intestine.
10
However, the
incidence of small bowel cancer, in general, is so low that
very few patients will have the disease. The most common
site for adenocarcinoma of the small intestine is in the
distal ileum. Any stricture must be examined to exclude
the possibility of carcinoma or dysplasia. The diagnosis
of small bowel carcinoma remains a challenge. Many of
these patients will be diagnosed at the time of laprotomy
or in the resected specimen. The incidence increases in the
bypassed segment from previous surgery. Therefore, even
the non-functioning rectal stump should be either excised
or the function restored. There is a 70 percent chance of
lymph node involvement at the time of initial diagnosis.
11
Therefore, overall prognosis remains poor.Treatment remains
resection for adenocarcinoma of the small intestine or colon.
If high grade dysplasia is diagnosed in Crohn’s disease, four
patients out of 10 (40 percent) had multifocal dysplasia at
remote sites.
6
In view of this, in a low risk, healthy patient,
total proctocolectomy should be considered.
Crohn’s colitis and toxic megacolon:
Many times these patients do not carry a well-established
diagnosis, whether it is ulcerative colitis or Crohn’s disease.
It is very important to establish correct diagnosis before
proceeding for a major proctocolectomy and ileoanal
pouch construction. The pouch failure rate in ileoanal
disease is up to 30 percent.
12
Ideally, a segmental resection
is advisable. If the disease is limited to the right colon, a
right hemicolectomy will suffice. If the disease is in the left
colon, a segmental resection should be performed to avoid
colostomy. The recurrence rate is 60 percent at five years.
13
It has been shown that when the disease is limited to the
colon without small bowel involvement, it does not recur
in the small intestine after proctocolectomy.
Toxic megacolon is not common inCrohn’s disease. How-
ever, if encountered and a short course of medical therapy
fails to treat the condition, a physician should be aggressive
with surgical intervention. Perforation in Crohn’s toxic
megacolon has up to a 45 percent mortality rate.
10
If there
is concomitant severe perineal infection at the same time, it
is best to avoid proctectomy at the initial surgery. Otherwise
it can result in perineal wound and severe sepsis. In these
cases, and when no clear diagnosis is established, abdominal
colectomy and ileostomy should be carried out initially.
Pregnancy and surgery in Crohn’s disease:
Usually these patients plan pregnancy when the disease
is inactive. If there is flare, medical treatment is carried out
aggressively. For surgical complications, MRI, ultrasound,
colonoscopy and other imaging techniques are used, depend-
ing upon the severity of the condition. Surgical treatment is
carried out based on the diagnosis. These patients do carry
a higher chance of developing anorectal suppuration and
genitourinary fistulas.
Intestinal transplant:
This a rare, difficult and challenging procedure with po-
tential for rejection even after immunosuppressive drugs. It
should only be performed in a highly selected patient who
has rather terminal bowel disease. Most of the intestine has
been resected prior to the transplant. There have been case
reports of patients developing Crohn’s disease eight years
post-transplant in the transplanted intestine.
14
Conclusion:
Even with the advent of ever-evolving newer drugs and
medical management of Crohn’s disease, surgery remains
an integral part of treatment to help patients improve and
continue with a better lifestyle. Management should be
carried out in close association with a gastroenterologist.
As much as possible, surgeons should use bowel sparing
procedures via minimally invasive techniques. Aggressive
surgical treatment should be carried out in conditions
causing septic complications.
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