Surgery for inflammatory bowel disease Flashcards
Important aetiological factors in inflammatory bowel disease
- Genetic predisposition
- Infection with unknown organisms
- Hypersensitivity to antigens in the luminal contents
What part of the GIT does ulcerative colitis usually affect
- Affects the colon
- Continuous disease that usually affects the rectum
- Extends for a variable distance proximally in the colon
Which part of the bowel does Crohns affect
- Any part from mouth to anus
- May be patchy with skip lesions
- Most commonly affects the terminal ileum and proximal colon
Which layers of the bowel wall does ulcerative colitis and crohns affect
- Ulcerative colitis: Involves mucosa
- Crohns: deep fissuring ulcers that penetrate through bowel wall to involve adjacent organs
Microscopic features of ulcerative colitis and Crohns disease
- Ulcerative colitis: Crypt abscesses
- Crohns: non-caseating granulomas
What is the significance of smoking in inflammatory bowel disease
Smoking is a promoter in Crohns but is protective in ulcerative colitis
Clincal presentation of inflammatory bowel disease
- Diarrhea with urgency with or without rectal bleeding associated with constitutional symptoms
- Crohn’s disease may also present with many other symptoms depending on the site
What diseases may crohns mimic
- Acute appendicitis
- Small bowel obstruction
- May present as perianal sepsis
Definition of acute severe attack of ulcerative colitis
- More than six stools a day associated with 2 or more of the following:
- Pyrexia
- Anaemia
- Tachycardia
Initial management of inflammatory bowel disease
- Resuscitation
- Confirm the diagnosis usually with gentle rigid or flexible sigmoidoscopy.
- Exclude infective diarrhea in all patients with stool culture
- Daily erect chest and abdominal xrays
- at least twice daily assessment by both medical and surgical gastroenterologist
- High dose IV steroids
- If the patient has not settled within 3-5 days, consider surgery or rescue therapy with cyclosporine or anti TNF agents
Causes of toxic megacolon
- Ulcerative colitis
- Crohn’s disease
- Amoebiasis
- Pseudomembranous colitis
Treatment of toxic megacolon
- On medical therapy: emergency colectomy
- Not on therapy: Short trial of medical therapy (hours) with progression to colectomy if the condition does not rapidly improve
Treatment of massive haemorrhage secondary to inflammatory bowel disease
- Medical management of the underlying disease
- Occasionally can be indication for urgent surgery
- Emergency situation: total colectomy and end ileostomy. The rectum is left in the patient with the proximal end closed off
What defines failed medical therapy of an acute severe attack of ulcerative colitis
- Patient partially responded
- The stool frequency may have decreased somewhat and they may or may not still have blood in their stools
- Attack however has not completely settled
- Considered to have failed if not responded at the end of 3-5 days of IV steroids
Operation of choice in patients with acute severe attack of colitis ho have failed medical therapy
colectomy and ileostomy. The rectum is not removed at this stage
Indications for emergency surgery
- Toxic megacolon
- Colonic perforation
- Massive haemorrhage
Indications for elective surgery?
- Chronic ill health: Underweight, chronically anaemic, significant side-effects of steroid usage, multiple hospital admissions for acute flares on the background of incomplete recovery
- Risk of malignancy
two methods of managing risk in patients with inflammatory bowel disease
- Proctolectomy
- Endoscopic surveillance: repeated colonoscopies at annual intervals from about 10 years from the start of disease
- Ignore the risk if first attack happens late in life
Operation for ulcerative colitis
- Proctocolectomy
- Restorative proctocolectomy
- Colectomy and ileostomy (acutely ill patient)
- Colectomy with ileorectal anastomosis (rectum retained)
Surgical management of crohns disease (anal disease)
- Abscesses require drainage
- Perinanal fistulas managed with setons
Surgical management of small bowel and colonic crohns disease
- If the surgeon is experienced and the segment of the disease is less than 10 cm; can resect it
- Not experienced; biopsy of a lymph node
- management of complications: strictures, enterocutaneous, enterovaginal and enterovesical fistulas
