Lesson 30: IPAA

Question 1

Indications

Answer 1

• patients requiring proctocolectomy d/t benign disease affecting both colon and rectum
• Sphincters must be intact
• Ulcerative colitis only; not Crohns
• Risk of recurrent disease in ileal pouch
• Patient’s ability to make an informed decision

Question 2

One-Stage Procedure - Criteria

Answer 2

Procedures
- removal of colon + rectum
- construction of Ileal pouch
- anastomosis to anal canal
- no ostomy

Criteria
- slender patient with mobile mesentary
- no steroids, anti-inflammatories, or Immunomodulators
- no nutritional deficits

Question 3

One-Stage Procedure - Management

Answer 3

Early issues = fecal urgency, leakage, and perianal skin breakdown
- BRAT diet
- Foods high in soluble fiber
- Fluids best consumed during meals

Initial post-op
- Avoid insoluble fiber = increases peristalsis
- Avoid citruses = increases perianal burning

Medications
- Bulking agents (ie. psyllium)
- Antidiarrheals (loperamide or diphenoxylate)

Behaviors
- Conscious effort to delay defection = increases pouch capacity
- Anal sphincter exercise to promote continence
- Perianal skin care

Question 4

Two-Stage Procedure - Criteria

Answer 4

Stage 1
- Removal of colon + rectum
- Construction of ileal pouch
- Anastomosis to anal canal
- Diverting loop ileostomy
Stage 2
- Takedown of the loop ileostomy

Criteria
- Anastomosis is under tension
- Impediments to normal healing
— Nutritional compromise
— Steroid use
— Use of anti-inflammatories

Question 5

Two-Stage Procedure - Management

Answer 5

Stage 1- Manage diverting loop ileostomy
- establish pouching system
- dehydration prevention
- dietary modifications to prevent blockage
- promote stage 2 readiness

Stage 2 - Management of fecal frequency + urgency
Initial Post-Op
- BRAT diet
- foods high in soluble fiber
- avoid insoluble fiber + citruses
Meds
- bulking agents
- antidiarrheals
Behaviours
- conscious effort to delay defecation
- anal sphincter exercises
- perianal skin care

Question 6

Three-Stage Procedure - Criteria

Answer 6

Stage 1
- Colectomy
- Hartmann’ Pouch
- End ileostomy
Stage 2
- Proctectomy
- Construction of ileal pouch
- Anastomosis to anal canal
- Diverting loop ileostomy
Stage 3
Takedown of diverting loop ileostomy

Criteria
- pregnant
- obese
- acutely ill
- at risk for impaired healing

Question 7

Three-Stage Procedure - Management

Answer 7

Stage 1 - manage end ileostomy
- Establish effective pouching system
- Instruction in self care
- Fluid management to prevent dehydration
- Dietary modifications to prevent blockage
- Promote stage 2 readiness
- Wean off anti-inflammatories
- Weight loss PRN
- Optimize nutritional status

Stage 2- manage diverting loop ileostomy
- Establish pouching system
- Dehydration prevention d/t high volume output
- Dietary modifications to prevent blockage
- Promote stage 3 readiness
- Sphincter strengthening exercises
- Dietary intake/bowel output chart

Stage 3- Manage fecal frequency + urgency
- dietary modifications
- bulking agents
- conscious effort to delay defecation
- anal sphincter exercises to promote continence