Transcript Inflammatory bowel disease

Inflammatory Bowel
Disease
Dr. Hagit Tulchinsky,
Proctology Unit, Surgery B
Tel Aviv Sourasky Medical Center
Epidemiology
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Developed countries
 More common in Jewish population (3-5 folds),
whites
 Equal distribution between genders
 Bimodal age distribution: 15-35y, 50-70y
Etiology-1
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UC and Crohn`s – separate entities ?
10-15% of IBD - Indeterminate colitis
10% - diagnosis is changed
Relatives – more likely to have the same disease as
the proband
Cluster within families
Etiology-2
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Genetic predisposition + environmental factors
(dietary intake)
Complex genetic disorder
UC - less significant genetic contribution than in
Crohn`s d.
Susceptibility locus, IBD 1, on chromosome 16
Molecular evidence of 2 forms of Crohn`s
pANCA – in most UC patients (75%)
Etiology-3
Host – defective mucosal barrier function
 NSAID`s exacerbate IBD
 Cigarette smoking: protective in UC, aggressive
factor in Crohn`s d.
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Etiology- Summary
These diseases are due to aberrant host
response to environmental antigens in
genetically susceptible individuals
Pathology-UC-1
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From rectum proximally
 Confined to colon and rectum
 Disease limited to the mucosa
 Macroscopic appearance
congested serosa
contracted and shortened bowel
edema of the mesentery
pseudopolyps
10% backwash ileities
Pathology-UC-2
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Microscopic appearance
Only the mucosa is affected
 Cancer and dysplasia
3-5% develop cancer
Increased risk if extensive disease for at least 8
years
Surgery if low grade dysplasia
Pathology
Crohn`s disease-1
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May affect any part of the intestinal tract
Usually affects the terminal ileum and cecum
Small bowel alone – 1/3
Colon alone – 1/3
Perianal region or upper GI tract alone – less
common
Pathology
Crohn`s disease-2
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Macroscopic appearance
Skip lesions
Segmental colitis
Stenosis of terminal ileum
Anal lesions in 75%
Wrapping of mesenteric fat
Thickened wall irregularly
Thickened mesentery
Pathology
Crohn`s disease-3
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Microscopic appearance
Patchy distribution
2/3 – noncaseating granulomas,
Transmural chronic inflammation,
Serositis, fibrous adhesions
Deep ulcers into the muscle layers
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Cancer and dysplasia
Increased risk in long standing disease
Pathology-Summery
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Pathologic features – more usually seen in chronic
stages of the disease
Cardinal feature of Crohn`s d. - patchiness
The presence of small bowel disease should
exclude UC
High or complex perianal fistula / anal ulceration
– more likely Crohn`s d.
Crypt distortion – characteristic of UC
Granulomas are less specific
Clinical findings
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Diarrhea, mucous discharge
Rectal bleeding- more UC
Obstructive symptoms- more Crohn’s d.
Anal/perianal d.- more Crohn’s d.
Loss of body weight
Anemia
Physical findings
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Reflect the severity of the disease
Abdominal tenderness (left side)
Abdominal distention
Fever, tachycardia
Proctitis- urgency, tenesmus, fecal incontinence
Extraintestinal manifestations
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Peripheral arthritis, 15-20%, resolve after colectomy
 Ankylosing spondylitis
 Sacroiliitis
 Primary sclerosing cholangitis – more in UC, no
resolution post op
Surgery-UC
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20-45% eventually undergo surgery
 Indications – elective / emergency
 Pre op. management:
- Correct hypovolemia + electrolytes
- Correct anemia
- If on steroids – Hydrocortisone I.V.
- Counseling and education on the outcome
- Severe malnutrition – TPN
- Prepare as for colon surgery
Indications for elective surgery
UC
Intractability – most common
 Involvement of other organs
 Large bowel dysplasia/cancer
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Indications for elective surgery
UC
Intractability
Failure of medical therapy
 Chronic complications of the disease
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Debilitating symptoms
Poor nutrition
Impaired quality of life
Anemia
Hypoproteinemia
Children- failure to growth
Side effects
Indications for elective surgery
UC
Presence and risk of cancer
When to consider prophylactic surgery/close
surveillance program?
 Extensive and long standing colitis
 Onset at childhood/teenage + generalized colitis +10
or more yrs of disease – 2% will develop cancer
each year
 PSC
 Dysplasia
Indications for elective surgery
UC
Debilitating extra intestinal manifestations
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May improve after surgery
Cutaneouos, peripheral arthicular, ocular,
hematological,vascular
 Ankylosing spondilitis and rheumatoid arthritis will
not regress
 PSC may progress to cirrhosis or cholangio ca. after
surgery
Indications for emergency surgery
UC
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Fulminant colitis
Tachycardia, fever, WBC > 10,500, low albumin
First – aggressive conservative treatment
Failure – surgery
Goal – operate before colonic perforation
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Toxic megacolon
Pain, fever, toxicity, abdominal tenderness and distention,
transverse colon >7cm
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Perforation, hemorrhage and obstruction
Choice of Operation-UC
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Restorative proctocolectomy
Treatment of choice if elective
CI – Crohn`s, incompetent sphincter,
cancer in distal rectum
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Proctectomy with continent ileostomy
Brooke ileostomy, poor sphincter
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Proctectomy with Brooke ileostomy
 Colectomy and ileorectal anastomosis
Rarely used today
only if relative rectum sparing, young males
Normal anatomy
Proctocolectomy
Colectomy with ileorectal
anastomosis
Choice of Operation
Elective treatment of choice
Restorative proctocolectomy with ileal
reservoir
The ileal pouch anal anastomosis
The pouch procedure
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Removes all of the colon and rectum
Preserves the anal canal
Aim – to avoid permanent ileostomy
The decision is up to the patient
Information on the pros and cons
The pouch procedure
WHO IS ELIGIBLE ?
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Ulcerative colitis and not Crohn`s disease
 Patients who had no operation
 Patients who had a colectomy with ileostomy or
ileorectal anastomosis
 Good anal sphincter control
The pouch procedure Technique
Stage 1- The pouch operation
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Abdomen opened
 Colon and rectum are freed
 Rectum is cut above the anal sphincter
 Small bowel and anus left in place
Abdominal incision
Proctocolectomy
The pouch procedure Technique
Stage 1- The pouch operation
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J pouch
 Pouch joined to the anus
 Protective loop ileostomy
ILEAL POUCH-ANAL
ANASTOMOSIS
The pouch procedure Technique
Stage 2 – Closure of ileostomy
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Relatively minor procedure
 Cut around the ileostomy
 Bowel closed
 The hole in the abdomen closed
The pouch procedure
Results
Early complications
 Obstruction
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Infection
The pouch procedure
Results
Late complications
 Obstruction
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Pouchitis
 Defecation problems
 Anal skin soreness
 Pouch fistula
The pouch procedure
Results
Function
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Frequency
 Urgency
 Continence
 Anti diarrheal medications
The pouch procedure
Results
Quality of life
90% - better
Failure
Up to 15%
Surgery
Crohn`s disease
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Typical presenting symptoms:
Abdominal pain, diarrhea, weight loss
 Reserved for patients whose quality of life is
significantly impaired despite appropriate medical
therapy or after disease associated complications
develop
 The probability of undergoing surgery is 78-90%
after 20 and 30 yrs, respectively
 Elective / emergent indications
Indications for elective surgery
Crohn`s disease
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Fistula ± abscess
The most common indication
Different types of fistula
Rarely heal with corticosteroids
6-MP will promote closure in 30-40%
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Obstruction
Chronic/acute
Single/multiple sites of stricture
Indications for elective surgery
Crohn`s disease
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Failed medical therapy
Incomplete response
Maintenance medications cannot be stopped
Significant side effects
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Intra abdominal abscess/fistula
 Carcinoma
 Growth retardation
15-30% of children with Crohn`s
Op. is indicated only in the pre pubertal child
Indications for emergency surgery
Crohn`s disease
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Fulminant colitis and Toxic megacolon
Acute flare and at least 2 of the following:
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Tachycardia >100 , fever >38.6, WBC > 10,500, albumin<3
Initial therapy –correct physiological deficits,
high dose steroids or immunosuppresants, bowel rest,
antibiotics
Any worsening during the initial 48h - surgery
Free perforation, massive hemorrhage, peritonitis, septic
shock – emergent op.
Indications for emergency surgery
Crohn`s disease
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Perforation
Most are sealed
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Massive bleeding
Rare – 1% of patients
Principles of operative treatment
Crohn`s disease
PALLIATIVE, CONSERVATISM
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Minimal procedure with maximal effect
Mechanical and antibiotic preparation
I.V. Steroids
Stop immunosuppressive therapy
Correction of deficits
Stoma marking
Operative options
Crohn`s disease
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Bypass
Rarely recommended – high recurrence rate and
malignancy risk
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Resection
Macroscopic healthy margins
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Anastomosis
Stapled or handsewn
Same principles as for any anastomosis
Operative options
Crohn`s disease
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Stricturoplasty
- Small bowel strictures, fibrotic recurrence at
ileocolic or ileoractal anastomosis
- Not for colonic narrowing
- Indications and contra indications
- Technique
STRICTUROPLASTY
(HEINEKE-MIKULICZ)
STRICTUROPLASTY
(FINNEY)
Thank You