Crohn's and UC Flashcards
Crohn’s
Bimodal distribution
Smoking is a risk factor
More common in high socioeconomic areas
Aphthous ulcers! Mucosal ulcers
Cobblestone mucosa
TPN, flagyl and infliximab can close fistulas.
Crohn’s disease is a significant risk factor to developing cholelithiasis. UNLIKE UC.
All IBD causes a hypercoagulable state
Crohn’s indication for surgery
Growth retardation is an indication for surgery
Unable to wean off or side effects from steroids is an indication for surgery
Perforation with Crohn’s
-MC ileum.
Terminal ileum resection for Crohn’s leads to: kidney stones, megaloblastic anemia, steatorrhea, and gallstones
Chron’s Surgical principles:
Surgical principles:
- Before operating: try to obtain enterography CT/MRI
- When operating due to complications of Crohn’s disease, you should ALWAYS try to avoid operating during an acute flare, unless it is emergent
- If patient with Crohn’s has abdominal abscess place drain, try to wait out inflammatory period before operating
- If operating in distal ileum due to stricture/perf/etc. the operation will be ileocectomy. Take the cecum
- If on Biologics or 5-ASA can continue them perioperatively
- Perianal, rectovesicular, rectovaginal fistula flagyl and infliximab is 1st line
- Crohn’s perforation, refractory toxic colitis, pancolitis with dysplasia total abdominal colectomy
- Resection margins = 2 cm grossly visible disease. Don’t worry about microscopic dz
- Crohn’s stricture in the 1st or 2nd portion of duodenum tx with gastrojejunostomy with highly selective vagotomy. Do a vagotomy BC these patients were found to have marginal ulcers
- Crohn’s stricture in the 3rd or 4th portion of duodenum duodenojejunostomy
- No whipple for duodenal Crohn’s
Chron’s Medical therapy
Treatment of mild active disease:
- Sulfasalazine
- Mesalamine Does not work on ileum!!! Don’t use for small bowel Crohn’s. Used mostly for UC. It has fewer side effects but is activated by colonic bacteria
Infliximab
– used if active disease refractory to prednisone OR to keep patients in remission
Increases risk of TB, multiple sclerosis, lymphoma and aspergillus infxn.
Crohn’s fistula, fissure, hemorrhoids
Crohn’s perianal fistula Infliximab, flagyl and seton
Fissure – no lateral internal sphincteroplasty
Hemorrhoids – no resection
Stricturoplasty for Crohn’s
Only performed for NON inflamed fibrotic small bowel strictures in Crohn’s
Not performed in colon
Distinguishing between inflammatory or fibrotic stricture:
- MRI enterography for small bowel
- Colonoscopy for large bowel
If resecting diseased bowel near stricture, just resect stricture too
Contraindicated in: bleeding, dysplasia, phlegmon, abscess, peritonitis, or long strictures
- Heineke-Mikulicz stricture < 10 cm.
- Finney 10-20 cm . Fold into U shape, enterotomy on entire length of U. Side to side isoperistaltic enteroenterostomy
- Jaboulay > 20 cm - Fold into U, enterotomy only at the opposed area distal to curve of U. Enteroenterostomy
- Risk of leaving CA behind. Make sure to bx ulcerations
- Has risk of blind loop, usually avoided
- Michelassi >20 cm– divide mesentery and small bowel at midpoint of stricture. Place proximal SB adjacent to distal and line up dilated to stenotic bowel. Perform long enterotomy on both bowel, and anastomose together.
Ulcerative colitis
Crypt abscesses. = hall mark of UC
p-ANCA
Smoking is protective
Perforation MC transverse colon.
All need colonoscopy 8 years after diagnosis for ALL IBD (crohn’s and UC) with 4 quadrant biopsies every 10 cm with at least 32 random biopsies
- High risk for CRC if patient has: pancolitis, PSC
- The above biopsy technique still missed a lot of cancer
- Now we have chromoendoscopy
o Mucosal dyes that enhance mucosal irregularities better at detecting dysplasia
o No random biopsy, only direct biopsy
Avoid NSAIDS, can cause flares
HLA B27 - sacroiliitis, ankylosing spondylitis, ulcerative colitis
Pyoderma gangrenosum treatment - steroids
Pouchitis – Ciprofloxacin treatment is better than flagyl
Many ileoanal J pouch (15%) need to eventually be taken down due to: incontinence (MC REASON), dysplasia/CA, refractory infectious pouchitis - TAKE DOWN WITH APR
MC long term complication of IPAA is pouchitis
If patient has UC and is diagnosed with primary sclerosing cholangitis, needs immediate colonoscopy and random bx. PSC increases risk of CRC significantly
At 20 years the case is strong for prophylactic colectomy in patients with: primary sclerosing cholangitis, family history of colon CA, young age at dx, left sided colitis
MC extra intestinal manifesting requiring total colectomy failure to thrive in children
Does not get better with total colectomy ankylosing spondylitis, sacroiliitis, and primary sclerosing cholangitis
Gets better ocular symptoms, arthritis, anemia, pyoderma gangrenosum
Severe colitis fulminant colitis (try medical tx 1st) progresses to toxic colitis/toxic megacolon (Colon >6 cm) = fever, tachycardia, leukocytosis
- If steroids fail, then give infliximab (90%) can avoid surgery
- No colonoscopy with toxic megacolon or toxic colitis
If patient has anal incontinence do not give J pouch ever, do total proctocolectomy with ileostomy
If surgery is emergent (perforation, high dose steroids, toxic colitis, unstable) subtotal colectomy with ileostomy
Ileal pouch anal anastomosis, J pouch: if you have tension creating the J pouch, do these maneuvers:
- Mobilize small bowel to the 3rd portion of duo
- Superficial dissection of anterior and posterior mesentery over tension lines along SMA vessels
Ulcerative colitis
-Chronic inflammatory condition affecting rectum and extending proximally (spares anus)
-Buzzwords: mucosal disease, contiguous (affects colon continuously), characteristic crypt abscesses, pseudopolyps
-Steroids for acute flares, mesalamine maintenance, infliximab added if resistant
-15-30% eventually requiring surgery
-Medical intractability (MC), malignancy (associated with prolonged inflammation), complications (stricture, perforation, fulminant/ toxic colitis)
-Disabling extra-intestinal manifestations that may respond to colectomy (e.g. large joint arthropathy, erythema nodosum, episcleritis)
-Hepatobiliary manifestations typically, do NOT respond to colectomy (e.g. primary sclerosing cholangitis)
-Surveillance recommendations: patients with extensive colitis (proximal to splenic flexure)
-Endoscopy after 8 years of disease, then every 1-2 years
-4 quadrant random biopsy should be performed at 10 cm intervals throughout involved segment of colon – along with directed biopsies of suspicion lesions
-Malignancy or high-grade dysplasia:
-Total proctocolectomy with or without IPAA (illeal pouch anal anastomosis)
-Surgical options:
-Emergent (toxic colitis, perforation): total or subtotal colectomy with end ileostomy; later may perform completion proctectomy and IPAA
-Elective:
-Total proctocolectomy with end ileostomy = curative, removes all pathologic tissue; lifelong ileostomy
-Total proctocolectomy with IPAA – MC procedure in elective setting
-No stoma, but may have pouch complications (e.g. pouchitis)
-Must have good baseline continence prior to IPAA
-Certain UC and not Crohn’s (Distal ileum used for ileal pouch)
-TAC with ileorectal anastomosis
-Must have uninvolved rectum (rare)
-Rectum risk for ongoing disease and CA
-Annual surveillance of residual rectal cuff
-Chron’s disease:
-Chronic, incurable, inflammatory disorder that can affect any segment of the intestinal tract (TI most common, usually spares rectum)
-Bimodal distribution (20-30s; 50-60s)
-Buzzwords: transmural involvement, segmental, characteristic creeping fat
-Phenotypes: inflammatory, fibrostenotic, penetrating (can overlap and change)
-Extraintestinal manifestations: arthritis/arthralgias, megaloblastic anemia (2/2 malabsorption of B12 in TI), uveitis, erythema nodosum
-Medical tx: steroids for acute flares, 5-ASA/mesalamine for maintenance, infliximab for resistant disease
-Surgery not curative unlike UC
-Reserved for dz complications: stricturing, obstruction, malignancy, perforation, fistula
-Preserve as much small bowel as possible (often multiple resections over lifetime)
-Symptomatic strictures: can1st try endoscopic dilation; resection or stricturoplasty
-Resection especially if isolated short segment disease
-Stricturoplasty useful for preserving bowel length if concern for short gut
-Short strictures (< 10 cm) – Heineke-Mikulicz stricturoplasty= Longitudinal incision on stricture and close transversely
-Medium-length strictures (10-20 cm) – Finney stricturoplasty= fold strictured segment on itself and make a common channel in the loop
-Long strictures (> 20 cm) – Michelassi= similar to Finney – side-to-side isoperistaltic stricturoplasty
-Bx of strictured segment
-Malnutrition, inflammation/ perforation/fistula, and suspicion for malignancy are contraindications for stricturoplasty
-Patient with prior proctocolectomy and IPAA for UC presents with fever, pelvic pain, and increased frequency of stools. Flexible endoscopy shows mucosal inflammation of ileal pouch. Diagnosis?
-Pouchitis
-Tx: Antibiotics (ciprofloxacin/metronidazole), supportive care; Budesonide enemas if not responsive to antibiotics
-Chronic pouchitis: suspect Crohn’s
-Pouchitis: inflammation of ileal pouch-anal anastomosis; caused by altered/ increased bacterial flora; sx= increased stool frequency + urgency, abdominal cramps, incontinence. Tx= abx, chronic/ severe/refractory= permanent diversion or pouch excision
-During laparoscopic exploration for presumed acute appendicitis, appendix appears normal, but TI inflamed. What do you do?
-Suspect Crohn’s; tx medically for acute Crohn’s flare.
-If cecum uninvolved: appendectomy to prevent future diagnostic confusion
-If cecum inflamed: leave appendix in place
