Crohn's Disease Of The Small Bowel

Question 0

What percentage of patients will have recurrence of Crohn’s disease requiring surgery?

Answer 0

50%

Question 1

What percentage of patients with Crohn’s disease will require surgery?

Answer 1

70%

Question 2

What are the most common locations of the GI tract involved in Crohn’s disease?

Answer 2

Terminal ileum (40%), colon (20%), jejunum & ileum (10%), anus (10%)

Question 3

What are the three major phenotypes of Crohn’s disease?

Answer 3

Stricturing, fistulizing and inflammatory

Question 4

Where does disease typically recur in Crohn’s ?

Answer 4

Disease tends to reappear in the same anatomical location. Disease behavior also recurs in the same way (fistulizing disease recurs with fistulas, etc)

Question 5

Which type is more responsive to medical therapy?

Answer 5

Inflammatory disease

Question 6

What is the initial management of Crohn’s?

Answer 6

Medical unless a complication has evolved (abscess, fistula, perforation, obstruction, GI hemorrhage or malignancy)

Question 7

What are the medications available for Crohn’s disease?

Answer 7

5-ASA derivatives, steroids, antibiotics, antimetabolites and anti-TNF medications

Question 8

What are some examples of 5-ASA derivatives? How do they work? How are the administered?

Answer 8

Sulfasalazine and mesalamine. They decrease inflammation through the arachidonic acid pathway. Can be administered orally or transrectally. They are not associated with increased perioperative complications and can be continued up until surgery and restarted immediately after surgery

Question 9

How can steroids be administered? What are the side effects? Should they be continued perioperatively?

Answer 9

Can be given orally, IV or rectally. Side effects include growth retardation, osteopenia, cushingoid features, systemic HTN, glomerular nephritis, cataracts, necrosis of the head of the femur and adrenal suppression. Long term use of steroids can lead to poor wound healing, increased risk for wound infection and can lead to perioperative adrenal crisis if stress doses are not given

Question 10

What are antibiotics used for? Which ones?

Answer 10

Used for acute inflammation and perianal disease. Fluoroquinolones, metronidazole, and rifaximin commonly used

Question 11

What are examples of antimetabolites (aka immunologics)? What is the function? What are side effects?

Answer 11

Azathioprine and 6-merceptopurine. They inhibit RNA synthesis and have a slow onset of action, and therefore are used for the maintenance of remission. Side effects include pancreatitis, bone marrow suppression and flulike symptoms

Question 12

What are some examples of anti-TNF medications (aka biologics)? What are the response rates? How do they work? How are they administered? What are the side effects?

Answer 12

Infliximab and adalimumab. Response rates up to 70% even in fistulizing disease. They reduce T-cell proliferation, decreasing inflammation. Medications administered IV or subQ. Side effects include infusion reactions, increased risk of infection and lymphoma. There may also be an increased risk or severity of perioperative infection

Question 13

What are the indications for surgery in Crohn’s disease?

Answer 13

The indications are divided into three categories: acute (perforation, sepsis, hemorrhage and toxic megacolon), subacute (neoplasia, abscess, obstruction, symptomatic fistula, refractory diarrhea, and malnutrition), and elective (recurrent/medically refractory disease, failure to wean/steroid dependence, and growth retardation in children)

Question 14

What is the most common indication for surgery?

Answer 14

Medically refractory Crohn’s disease

Question 15

Do internal fistulas require surgery?

Answer 15

They may be asymptomatic and may not require surgery. Any fistula causing a functional bypass leading to excessive diarrhea or malabsorption may require surgery

Question 16

What is the initial treatment of intraabdominal abscess in Crohn’s disease?

Answer 16

If stable, initial treatment is CT or U/S guided drainage and antibiotics

Question 17

What are some basic tenets of Crohn’s disease surgery?

Answer 17

The small bowel should be inspected from ligament of Treitz to ileocecal valve. Measurements of the total length of small bowel and the extent and location of diseased segments should be noted

Question 18

How should bowel resection be performed?

Answer 18

Only severely diseased and symptomatic segments of bowel should be resected. Mildly diseased segments (with creeping fat and corkscrew vessels) are not indications for resection. Also, do not need microscopically negative margins