Crohn’s Disease of the Small Bowel

Question 1

MC Location ?

Answer 1

Most commonly, it occurs in the small intestine with the terminal ileum being the most common location.

Question 2

The clinical hallmark of Crohn’s disease

Answer 2

abdominal pain and diarrhea.

Question 3

What imaging Studies are essential in the initial evaluation

Answer 3

CT enterography and MRI enterography

Question 4

Other Studies ?

Answer 4

1-Endoscopy and colonoscopy are performed for direct visualization of bowel mucosa and to obtain tissue diagnosis.

2-Capsule endoscopy for further direct evaluation of the small bowel mucosa.

Question 5

At initial presentation With Numbers

Answer 5

40% terminal ileal disease

20% colonic disease

10% proximal small bowel disease

10% perianal disease

20% will have involvement of more than one anatomic location.

Question 6

Mild to moderate disease Tx

Answer 6

Standard initial management

5-aminocalycylates or budesonide depending on the location of disease.

Question 7

Acute flares Tx

Answer 7

short courses of corticosteroids with transition to maintenance therapy once an adequate remission has been achieved.

Question 8

moderate to severe disease

Answer 8

TNF inhibitors

Question 9

Studies have shown fistula resolution and combination therapy with

Answer 9

methotrexate has demonstrated high mucosal healing rates

Question 10

The main indications for surgery in Crohn’s disease

Answer 10

obstruction
perforation
failure of medical management.

Question 11

Patients with long-standing Crohn’s disease are at increased risk of developing

Answer 11

adenocarcinoma

Question 12

chronic partial obstruction that exists between episodes of acute inflammation referred to as

Answer 12

fibrostenotic stricture.

Question 13

in obstructed Patient MRI and CT enterography can differentiate (not 100% Though) between

Answer 13

stricture that is largely inflammatory versus one that is largely fibrostenotic.

Question 14

Another way to differentiate is ?

Answer 14

once the patient is treated and now asymptomatic, imaging is repeated.

If persistent dilation of the bowel proximal to the stricture is appreciated, predominant fibrostenotic disease is assumed

Question 15

fibrostenotic disease is an indication for ?

Answer 15

Surgical intervention

Question 16

How to know when to intervene for abscess ?

Answer 16

small resolved abscess on minimal medical therapy would likely benefit from medical escalation

whereas a resolved abscess in a patient who has failed three biological medications would likely be offered surgery.

Question 17

How does Fistula happen ?

Answer 17

localized perforation > abscess formation> fistulization.

Question 18

Does enteroenteric or enterocolonic fistula indications for Sx ?

Answer 18

Only when the fistula causes worsening clinical symptoms or nutritional deficiencies should surgery be performed.

Question 19

Enterovesical fistulas can lead to ?

Answer 19

Recurrent urinary tract infections
pyelonephritis
urosepsis.

In addition, the symptoms of pneumaturia and fecaluria are generally intolerable to most patients.

Question 20

enterocutaneous fistulas ?

Answer 20

require surgical intervention

because of chronic drainage from the abdominal wall, chronic abdominal wall wounds
dehydration
frequent nutritional deficiencies.

Question 21

Absolute indication for Sx ?

Answer 21

inability to wean steroids after an acute flare and transition to maintenance therapy is an absolute indication for surgery.

Question 22

when a significant length of bowel is at risk

Answer 22

bowel rest and total parenteral nutrition may be required.

Question 23

Bowel Prep in Crohns ?

Answer 23

-A standard mechanical bowel preparation with oral antibiotics is given unless a prolonged high-grade bowel obstruction is present

-In this case, an extended period of clear liquid diet is employed.

Question 24

All efforts should be made to wean or discontinue steroids before surgery Why ?

Answer 24

adversely affect wound healing and to increase the risk of surgical site infection.

Question 25

what about TNF ?

Answer 25

the literature provides no definitive guidance on this matter.

Some studies have shown no effect

others showing a significantly increased incidence of infectious complications when patients have taken the medications within 6 to 8 weeks before surgery.

Question 26

when patients are on long-term steroid treatment you should conside ?

Answer 26

bowel diversion with stoma creation

Question 27

What about TNF inhibitor

Answer 27

true to a lesser extent

Question 28

TECHNICAL CONSIDERATIONS FOR SURGICAL INTERVENTION

Answer 28

CT or MRI enterography
capsule endoscopy
small bowel push enteroscopy
The colon should be evaluated via colonoscopy. The cecum and the terminal ileum in particular
Endoscopy should be performed for disease in the duodenum and proximal jejunum.

Question 29

situation in Ot : If isolated mid small bowel disease is noted

Answer 29

externalized through extension of the umbilical port for resection and re-anastomosis.

Question 30

Enteroenteric fistula of the terminal ileum to itself

Answer 30

preserved as the entire segment of bowel usually requires en bloc resection as an inflammatory mass.

Question 31

If the terminal ileum is fistulizing to otherwise “innocent” portions of the GI tract

Answer 31

the fistula must be transected and the healthy bowel must be assessed.

-small bowel to sigmoid colon fistula.
fistula opening in the sigmoid colon debrided to healthy tissue and closed primarily.
handsewn two-layer approach

colonic resection will be required given associated inflammation in the area.

similar approach to fistulas must be employed for “innocent” small bowel involvement.

Question 32

fistula to the bladder ?

Answer 32

taken down with primary repair of the bladder if a definite opening is noted, and prolonged Foley catheter drainage is performed.

The catheter is removed after CT cystogram confirms healing of the bladder.

Question 33

if during mobilization , you cant see the ureter due to severe Inflammation ?

Answer 33

dissection of the ureter should be performed in the pelvis to better evaluate its course.

If this was predicted > preoperative ureteral catheter placement should be performed.

Question 34

The basic principle of small bowel resection for Crohn’s disease

Answer 34

remove all of the grossly involved disease while preserving as much bowel length as possible.

Question 35

Grossly involved bowel is best determined by

Answer 35

visual and tactile evaluation.

Question 36

what about Fat creeping

Answer 36

should not be present
and the mesenteric margin should be palpable in unaffected intestine.

Question 37

Indications for Ileostomy

Answer 37

extensive contamination from a drained abscess
the bowel is noted to be significantly dilated precluding healthy anastomosis.
High-dose steroid use
severe malnutrition

Question 38

When proximal diversion is required??

Answer 38

when significant inflammation of long segments of small intestine are noted

too much bowel is involved to resect,

and proximal diversion is performed as a last-ditch effort to induce remission.

Question 39

Proximal Diversion will results in ?

Answer 39

high-output stoma requiring parenteral nutrition.

Question 40

Disease of the Duodenum, Diagnosed With ?

Answer 40

imaging and upper endoscopy.

Question 41

Initial attempts at management

Answer 41

endoscopic balloon dilation > Recurrence is Common

Question 42

When surgery is indicated

Answer 42

strictureplasty is the procedure of choice.

If the disease is too diffuse > Gastrojejunostomy

Question 43

Before the Bypass, what do you want to do ?

Answer 43

pH study to determine the need for vagotomy.

when possible > gastroduodenal bypass is recommended for proximal disease of the duodenum to prevent marginal ulceration

Question 44

How to determine clinically significant strictures.

Answer 44

inflating a Foley catheter with 3 mL to 10 mL of saline and inserting it into the bowel through an enterotomy

Question 45

Once it has been determined that a strictureplasty is to be performed

Answer 45

mucosa must be examined once opened
Biopsies with possible frozen section must be performed if malignancy is suspected.

Question 46

Heineke-Mikulicz Strictureplasty

Answer 46

-for strictures less than 7 cm in length.

-An incision is made on the antimesenteric border.
-extend 2 cm past the active inflammation on either side. -The incision is then reapproximated transversely.

Question 47

Finney Strictureplasty

Answer 47

-between 8 and 15 cm Strictures

-longitudinal incision is made on the antimesenteric border then closed as a U-shaped enterotomy with the ‘‘bowel folded’’ on itself at the midpoint of the enterotomy.

Question 48

(Michelassi Strictureplasty) Side to Side

Answer 48

-allows for preservation of long segments
-transection of actively inflamed portions of small intestine and aligning them in isoperistaltic side-to-side fashion.

Question 49

It is assumed that Crohn’s disease will recur and that it will do so at

Answer 49

a microscopic level early at the anastomotic site.