Crohn’s Disease and Crohn’s Disease and other Diseases of the other Diseases of the Small BowelSmall Bowel

Anir Gupta, MD, FRCSCAnir Gupta, MD, FRCSCAssistant ProfessorAssistant ProfessorDepartment of SurgeryDepartment of Surgery

Case 1Case 1 A 45 yo M with a history of AIDS A 45 yo M with a history of AIDS

presents to your ED with nausea, presents to your ED with nausea, vomiting, diarrhea and severe vomiting, diarrhea and severe abdominal pain. How would you abdominal pain. How would you approach this patient?approach this patient?

CMV EnteritisCMV Enteritis

Most commonly affects the distal Most commonly affects the distal ileum and right colonileum and right colon

Colonoscopic findings include Colonoscopic findings include hemorrhagic, ulcerated lesionshemorrhagic, ulcerated lesions

Cytology: nuclear inclusions Cytology: nuclear inclusions “owl’s eye”“owl’s eye”

Treatment: medical, not surgicalTreatment: medical, not surgical– Gancyclovir/foscarnetGancyclovir/foscarnet

Case 2Case 2

A 35 yo M who is otherwise A 35 yo M who is otherwise healthy presents to your ED with healthy presents to your ED with fever, diarrhea and RLQ fever, diarrhea and RLQ abdominal pain. How would you abdominal pain. How would you approach this patient?approach this patient?

Acute IleitisAcute Ileitis

Etiology may be infectious or inflammatory Etiology may be infectious or inflammatory (ie Crohn’s Disease)(ie Crohn’s Disease)

Predominant etiology: infectiousPredominant etiology: infectious Usual suspects:Usual suspects:

– CampylobacterCampylobacter– Yersinia Yersinia – SalmonellaSalmonella– Shigella Shigella

Investigations – do a C&S, O&P !Investigations – do a C&S, O&P ! Mimics: appendicitis, crohn’s diseaseMimics: appendicitis, crohn’s disease Treatment: antibiotics, not surgery!Treatment: antibiotics, not surgery!

Case 3Case 3

57 yo man presents to your hospital 57 yo man presents to your hospital with nausea, vomiting, and crampy with nausea, vomiting, and crampy abdominal pain. Past medical history abdominal pain. Past medical history significant for Crohn’s Disease. How significant for Crohn’s Disease. How would you approach this patient?would you approach this patient?

Abdominal CTAbdominal CT

Crohn’s DiseaseCrohn’s Disease

PrevalencePrevalence– 4-10 per 100,0004-10 per 100,000– More prevalent in northern US and Ashkenazi pop.More prevalent in northern US and Ashkenazi pop.– Bimodal distribution (30’s and 60’s)Bimodal distribution (30’s and 60’s)

Genetic and environmentGenetic and environment– 1:5 have a family member with Crohn’s1:5 have a family member with Crohn’s– NOD2 gene mutation = 40X risk of crohn’sNOD2 gene mutation = 40X risk of crohn’s

Chronic disease with acute flaresChronic disease with acute flares– Different treatments for each phaseDifferent treatments for each phase– Goal is to delay surgery and improve QOLGoal is to delay surgery and improve QOL– No cure, only palliationNo cure, only palliation

Symptoms of Crohn’s Symptoms of Crohn’s DiseaseDisease Abdominal painAbdominal pain DiarrheaDiarrhea Weight lossWeight loss Failure to thrive for childrenFailure to thrive for children

ComplicationsComplications– Abscess – feversAbscess – fevers– Fistulas – draining wounds, diarrheaFistulas – draining wounds, diarrhea– ObstructionObstruction

Crohn’s DiseaseCrohn’s Disease

Often difficult to delineate between Often difficult to delineate between Crohn’s and Ulcerative ColitisCrohn’s and Ulcerative Colitis– 15% have “indeterminate” colitis15% have “indeterminate” colitis

Crohn’sCrohn’s– Sustained inflammationSustained inflammation– Mouth to anusMouth to anus– TransmuralTransmural– TypesTypes

FistulizingFistulizing Fibrostenotic (stricturing)Fibrostenotic (stricturing) InflammatoryInflammatory

Crohn’s DiseaseCrohn’s Disease

Crohn’s DiseaseCrohn’s Disease

Areas of involvementAreas of involvement– Ileocecal – 70%Ileocecal – 70%– Colon only – 20%Colon only – 20%– Small bowel only ~ 5%Small bowel only ~ 5%– Perineal/anorectal ~ 10%Perineal/anorectal ~ 10%– Esophagus, stomach, Esophagus, stomach,

duodenum ~ 1-5%duodenum ~ 1-5%

Extraintestinal Extraintestinal ManifestationsManifestations

Pathologic findingsPathologic findings

EndoscopyEndoscopy– Linear ulcersLinear ulcers– Cobblestone (coalescence of ulcers)Cobblestone (coalescence of ulcers)– Skip lesionsSkip lesions

BiopsyBiopsy– Transmural involvementTransmural involvement– Apthous ulcersApthous ulcers– Noncaseating GranulomasNoncaseating Granulomas

Endoscopic findings in Endoscopic findings in Crohn’sCrohn’s

Linear ulcerSerpiginous ulcer

Endoscopic findings in Endoscopic findings in Crohn’sCrohn’s

Cobblestoning

Radiologic findings in Radiologic findings in Crohn’sCrohn’s

Treatment of Crohn’sTreatment of Crohn’s

Goals change based on presentationGoals change based on presentation– AcuteAcute

Treat complications (abscess, fistula, Treat complications (abscess, fistula, obstruction)obstruction)

Improve symptomsImprove symptoms Avoid surgery??Avoid surgery?? Return to chronic phaseReturn to chronic phase

– Chronic phaseChronic phase Improve QOLImprove QOL Maintain remissionMaintain remission Prevent flaresPrevent flares

Medical Treatment for Medical Treatment for Crohn’sCrohn’s Acute phaseAcute phase

– Antibiotics for abscess/infectionAntibiotics for abscess/infection Drain placement for large abscessesDrain placement for large abscesses

– Steroid pulse (systemic)Steroid pulse (systemic)– ImmunomodulatorsImmunomodulators

Infliximab (remicade) or adalimumab Infliximab (remicade) or adalimumab (humira)(humira)

– NPO statusNPO status– Nutritional supportNutritional support

Medical Treatment for Medical Treatment for Crohn’sCrohn’s Chronic phase (Maintenance therapy)Chronic phase (Maintenance therapy)

– Anti-inflammatoryAnti-inflammatory 5-Aminosalicylic acid (5-ASA)5-Aminosalicylic acid (5-ASA)

– Mesalamine, mesalazine, sulfasalazine, PentasaMesalamine, mesalazine, sulfasalazine, Pentasa SteroidsSteroids

– Topical and systemicTopical and systemic– AntibioticsAntibiotics

Cipro for perineal diseaseCipro for perineal disease Flagyl following surgical resectionFlagyl following surgical resection

– ImmunomodulatorsImmunomodulators AzathioprineAzathioprine 6-mercaptopurine (6-MP)6-mercaptopurine (6-MP) CyclosporineCyclosporine MethotrexateMethotrexate Infliximab (remicade)Infliximab (remicade)

– Monitor for development of neoplasia/dysplasiaMonitor for development of neoplasia/dysplasia Colonoscopy every 2-3years after first 10 years of diagnosisColonoscopy every 2-3years after first 10 years of diagnosis

Surgery for Crohn’s Surgery for Crohn’s DiseaseDisease IndicationsIndications

– ComplicationsComplications Abscess, perforation, fistula, obstruction, Abscess, perforation, fistula, obstruction,

bleedingbleeding

– Failure of medical managementFailure of medical management– Intolerance of medical therapyIntolerance of medical therapy– Development of neoplasiaDevelopment of neoplasia

Most patients will eventually require Most patients will eventually require surgerysurgery

Surgery for Crohn’s Surgery for Crohn’s DiseaseDisease Removal of diseased intestineRemoval of diseased intestine

– Most common operation is Most common operation is ileocecectomyileocecectomy

– Several segmental resections better Several segmental resections better than one long segment resectionthan one long segment resection

Stricuroplasty for short or Stricuroplasty for short or numerous stricturesnumerous strictures

Drainage of abscessesDrainage of abscesses

Surgery for Crohn’sSurgery for Crohn’s

“Creeping fat” Inflammation of terminal ileum (right) and cecum (left) in ileocolectomy specimen

Surgical outcomesSurgical outcomes

Complication rates highComplication rates high– 15-30%15-30%– Wound infectionWound infection– Anastomotic leaksAnastomotic leaks

Good short-term resolution of Good short-term resolution of symptomssymptoms

Duration of benefit dependent on Duration of benefit dependent on severity of diseaseseverity of disease

Surgery begets more surgery for Surgery begets more surgery for crohn’s patientscrohn’s patients

Case 4Case 4 57 yo F comes to your hospital with a 57 yo F comes to your hospital with a

2 day history of nausea, vomiting, 2 day history of nausea, vomiting, and abdominal pain. Her past and abdominal pain. Her past surgical history is significant for a c-surgical history is significant for a c-section in the past. She does not take section in the past. She does not take any meds, no drug allergies, no other any meds, no drug allergies, no other medical problems. She is mildly medical problems. She is mildly tachycardic, otherwise VSS. How tachycardic, otherwise VSS. How would you approach this patient?would you approach this patient?

Abdominal seriesAbdominal series

Case 5Case 5

72 yo F comes into your ED with 3 72 yo F comes into your ED with 3 day history of nausea, vomiting and day history of nausea, vomiting and obstipation. She is tachycardic, has obstipation. She is tachycardic, has a low grade fever, and her SBP is 90. a low grade fever, and her SBP is 90. Labs reveal a WBC of 13,000. How Labs reveal a WBC of 13,000. How would you approach this patient?would you approach this patient?

Abdominal CTAbdominal CT

Infarcted Small BowelInfarcted Small Bowel

Case 6Case 6

You are asked to see an 69 yo F on You are asked to see an 69 yo F on the medical service. She has been the medical service. She has been obstipated for 2 days. She is obstipated for 2 days. She is tachycardic, her SBP is 90, her tachycardic, her SBP is 90, her abdomen is distended and tympanitic. abdomen is distended and tympanitic. The ER doctor is concerned about a The ER doctor is concerned about a mass in her right groin that he feels is mass in her right groin that he feels is concerning for an abscess. How would concerning for an abscess. How would you approach this patient?you approach this patient?

Abdominal CTAbdominal CT

Case 7Case 7

A 54 yo M comes to your hospital with a A 54 yo M comes to your hospital with a 3 day history of nausea, vomiting and 3 day history of nausea, vomiting and severe abdominal pain. He states that severe abdominal pain. He states that he has been suffering from chronic he has been suffering from chronic abdominal pain for several months now. abdominal pain for several months now. He has lost 20 lbs in the past few He has lost 20 lbs in the past few months. He is tachycardic, with a months. He is tachycardic, with a distended, diffusely tender abdomen. distended, diffusely tender abdomen. How would you approach this patient?How would you approach this patient?

CXRCXR

Omental CakeOmental Cake

Case 8Case 8

A 65 yo F with a previous history A 65 yo F with a previous history of melanoma presents to your of melanoma presents to your hospital with nausea, vomiting hospital with nausea, vomiting and recurrent abdominal pain. and recurrent abdominal pain. She is anemic. How would you She is anemic. How would you approach this patient?approach this patient?

Abdominal CTAbdominal CT

Case 9Case 9

You have been referred a patient You have been referred a patient with chronic intermittent abdominal with chronic intermittent abdominal pain. EGD is normal. Colonoscopy pain. EGD is normal. Colonoscopy is normal. Patient is not obstipated, is normal. Patient is not obstipated, but does experience intermittent but does experience intermittent bloating and “constipation” along bloating and “constipation” along with his pain. How would you with his pain. How would you evaluate this patient?evaluate this patient?

Small bowel follow Small bowel follow throughthrough

EnteroclysisEnteroclysis

Capsule EndoscopyCapsule Endoscopy

Case 10Case 10

A 65 yo F presents to your ED A 65 yo F presents to your ED with nausea, vomiting and with nausea, vomiting and abdominal pain. She is abdominal pain. She is obstipated. She has had surgery obstipated. She has had surgery and adjuvant therapy in the past and adjuvant therapy in the past for ovarian cancer. How would for ovarian cancer. How would you approach this patient?you approach this patient?

Abdominal CTAbdominal CT

Bowel obstructionBowel obstruction

Bowel obstructionBowel obstruction

Definition: a mechanical blockage of the Definition: a mechanical blockage of the intestine preventing passage of intestine preventing passage of intestinal secretions and contentsintestinal secretions and contents

Etiology:Etiology:– IntraluminalIntraluminal– IntramuralIntramural– ExtrinsicExtrinsic

Most common reason for emergency Most common reason for emergency general surgery admissiongeneral surgery admission– Approximately ½ million yearlyApproximately ½ million yearly– 300,000 per year will be operated on for SBO300,000 per year will be operated on for SBO

Etiology of Bowel Etiology of Bowel ObstructionObstruction

– Previous operation – about 50% will need Previous operation – about 50% will need surgerysurgery

Adhesions – account for 75% of all obstructionsAdhesions – account for 75% of all obstructions

– No previous operation – No previous operation – allall need need surgery/interventionsurgery/intervention

HerniaHernia Malignancy/tumorMalignancy/tumor Crohn’s diseaseCrohn’s disease Malrotation/volvulusMalrotation/volvulus IntussusceptionIntussusception DiverticulitisDiverticulitis Stricture (ischemic, radiation, crohn’s)Stricture (ischemic, radiation, crohn’s)

Bowel obstruction Bowel obstruction pathophysiologypathophysiology

– gas and fluid accumulation proximal gas and fluid accumulation proximal to obstructionto obstruction

– increased intraluminal pressureincreased intraluminal pressure– bowel distensionbowel distension– decreased motilitydecreased motility– increased bacterial load and change increased bacterial load and change

to anaerobesto anaerobes

Classification of Bowel Classification of Bowel ObstructionObstruction

PartialPartial– AdhesionsAdhesions

CompleteComplete– AdhesionsAdhesions– HerniaHernia– MalignantMalignant

Closed loopClosed loop– AdhesionsAdhesions– VolvulusVolvulus

Symptoms of Symptoms of obstructionobstruction Colicky abdominal painColicky abdominal pain NauseaNausea VomitingVomiting

– Bilious vomitingBilious vomiting– Feculence suggests long standing or distal Feculence suggests long standing or distal

obstructionobstruction ObstipationObstipation Inability to tolerate some more solid Inability to tolerate some more solid

foodsfoods

Exam findings of Exam findings of obstructionobstruction Abdominal distensionAbdominal distension

– May be minimal or absent in proximal May be minimal or absent in proximal obstructionsobstructions

Hypoactive or high-pitched bowel Hypoactive or high-pitched bowel soundssounds

Pain with exam usually requires urgent Pain with exam usually requires urgent operationoperation

ALWAYS, ALWAYS, ALWAYSALWAYS, ALWAYS, ALWAYS– Check for herniasCheck for hernias– Rectal examRectal exam

Laboratory findings in Laboratory findings in obstructionobstruction Volume depletionVolume depletion

– Increased BUN/CreatinineIncreased BUN/Creatinine– HypokalemiaHypokalemia

LeukocytosisLeukocytosis– Worrisome if more than mild elevationWorrisome if more than mild elevation

Acidosis (metabolic/lactic)Acidosis (metabolic/lactic)– NotNot a good indicator of ischemia because a good indicator of ischemia because

of venous mesenteric obstructionof venous mesenteric obstruction

Radiology for bowel Radiology for bowel obstructionobstruction Extent of obstructionExtent of obstruction Closed loopClosed loop PerforationPerforation HerniaHernia Transition pointTransition point Determine need for operationDetermine need for operation

CTCT

Ventral hernia causing obstruction Intussusception

Other imaging studiesOther imaging studies

Small bowel follow throughSmall bowel follow through EnteroclysisEnteroclysis Capsule endoscopyCapsule endoscopy Gastrograffin enemaGastrograffin enema

Gastrograffin enemaGastrograffin enema

Initial managementInitial management

IVF resuscitationIVF resuscitation– Isotonic (LR or NS)Isotonic (LR or NS)– Electrolyte replacementElectrolyte replacement

NGT decompressionNGT decompression NPONPO AdmissionAdmission

Definitive Definitive managementmanagement Expectant / conservative (Non-operative)Expectant / conservative (Non-operative)

– Adhesions – Partial obstructionAdhesions – Partial obstruction– Crohn’sCrohn’s– Early post-operativeEarly post-operative

OperativeOperative– Complete/high-grade obstruction from Complete/high-grade obstruction from

adhesionsadhesions– Closed loopClosed loop– IschemiaIschemia– Clear transition point on CTClear transition point on CT– NOT due to adhesionsNOT due to adhesions

Cancer, volvulus, hernia, strictureCancer, volvulus, hernia, stricture– Failure to improve with non-operative treatmentFailure to improve with non-operative treatment

Surgery for Surgery for obstructionobstruction Laparoscopic or OpenLaparoscopic or Open Lysis of adhesions Lysis of adhesions Examine entire length of bowelExamine entire length of bowel Resection of ischemic segmentsResection of ischemic segments

– 22ndnd look if viability is questioned look if viability is questioned Repair hernia/volvulusRepair hernia/volvulus Adhesion preventionAdhesion prevention

– Hyaluronan-based agents (Seprafilm)Hyaluronan-based agents (Seprafilm)

Post-operative Post-operative managementmanagement NGT decompressionNGT decompression Await return of bowel functionAwait return of bowel function Consider nutritional support after Consider nutritional support after

5-7 days5-7 days Risk of recurrenceRisk of recurrence

– 20-50% due to adhesions20-50% due to adhesions

Small Bowel TumorsSmall Bowel Tumors

PrimaryPrimary– AdenocarcinomaAdenocarcinoma– CarcinoidCarcinoid– LymphomaLymphoma– GISTGIST

MetsMets– MelanomaMelanoma– OthersOthers

Small Bowel TumorsSmall Bowel Tumors

AdenocarcinomaAdenocarcinoma– Most common in the duodenum and Most common in the duodenum and

proximal jejunumproximal jejunum– ~ 50% of primary small bowel ~ 50% of primary small bowel

malignanciesmalignancies– Treatment: wide surgical resection Treatment: wide surgical resection

and lymphadenectomyand lymphadenectomy– No benefit to chemo/radNo benefit to chemo/rad– Mainly palliativeMainly palliative

Small Bowel TumorsSmall Bowel Tumors

CarcinoidCarcinoid– Arise from the enterochromaffin cells in the cysts Arise from the enterochromaffin cells in the cysts

of Lieberkuhnof Lieberkuhn– Secrete various active peptidesSecrete various active peptides– 22ndnd most common site is the small bowel most common site is the small bowel– Usually asymptomaticUsually asymptomatic– May cause abdominal pain and weight lossMay cause abdominal pain and weight loss– Diagnosis Diagnosis

24 hr urine for 5-HIAA24 hr urine for 5-HIAA Chromogranin AChromogranin A Octreotide scan (Serotonin Receptor Scintigraphy)Octreotide scan (Serotonin Receptor Scintigraphy)

– Treatment Treatment Wide surgical resectionWide surgical resection

Small Bowel TumorsSmall Bowel Tumors

GISTGIST– Rare submucosal tumorRare submucosal tumor– Most common GI sarcomaMost common GI sarcoma– Previously referred to as leiomyoma or leimyosarcomaPreviously referred to as leiomyoma or leimyosarcoma– Peak incidence in 5Peak incidence in 5thth and 6 and 6thth decades decades– 90% positive for KIT (CD 117)90% positive for KIT (CD 117)– Arise from pacemaker cells of the intestine, the Arise from pacemaker cells of the intestine, the

Interstitial Cells of CajalInterstitial Cells of Cajal– Treatment for primary, non metastatic disease: Treatment for primary, non metastatic disease:

surgerysurgery– Adjuvant therapy for unresectable tumors: GleevecAdjuvant therapy for unresectable tumors: Gleevec– Survival predicated on tumor size and # of mitoses/50 Survival predicated on tumor size and # of mitoses/50

HPFHPF

Case 11Case 11

77 yo F presents to your ED with 77 yo F presents to your ED with a history of acute onset severe a history of acute onset severe abdominal pain that “woke her up abdominal pain that “woke her up at 3 AM”. Past medical history is at 3 AM”. Past medical history is significant for CAD, MI and Afib. significant for CAD, MI and Afib. Past surgical history is significant Past surgical history is significant for right fem-pop bypass for for right fem-pop bypass for peripheral vascular disease. How peripheral vascular disease. How would you approach this patient? would you approach this patient?

Abdominal CTAbdominal CT

Mesenteric IschemiaMesenteric Ischemia

ArterialArterial– EmbolicEmbolic

Arrhythmias Arrhythmias Post MIPost MI Structural heart disease Structural heart disease

– ThromboticThrombotic AtherosclerosisAtherosclerosis Age Age

Venous ThrombosisVenous Thrombosis– Hypercoagulable statesHypercoagulable states– Inflammation Inflammation – MalignancyMalignancy– Cirrhosis Cirrhosis

NOMI (Non Occlusive Mesenteric Ischemia)NOMI (Non Occlusive Mesenteric Ischemia)– Low flow statesLow flow states

Numerous Pathologic Numerous Pathologic Processes affect the Processes affect the Same Organ…Same Organ… InfectiousInfectious

– CMV/Yersinia/CampylobacterCMV/Yersinia/Campylobacter InflammatoryInflammatory

– CD/Radiation enteritisCD/Radiation enteritis NeoplasticNeoplastic

– BenignBenign adenomasadenomas

– MalignantMalignant PrimaryPrimary

– AdenocarcinomaAdenocarcinoma– Carcinoid Carcinoid – Lymphoma Lymphoma

MetsMets– MelanomaMelanoma

AnatomicAnatomic– Adhesions Adhesions – Hernias Hernias

IschemicIschemic– EmbolicEmbolic– ThromboticThrombotic– Venous ThrombosisVenous Thrombosis– NOMINOMI

History, physical, labs History, physical, labs and imaging will guide and imaging will guide your differential …your differential … RLQ painRLQ pain

– AnatomicAnatomic– InfectiousInfectious– NeoplasticNeoplastic

ObstructionObstruction– AnatomicAnatomic– InflammatoryInflammatory– NeoplasticNeoplastic

Final PointsFinal Points

Bowel obstruction without history of Bowel obstruction without history of abdominal surgery usually means they abdominal surgery usually means they need surgeryneed surgery

Conservative management for bowel Conservative management for bowel obstruction requires close follow-up obstruction requires close follow-up and decision makingand decision making

Crohn’s disease is a chronic disease Crohn’s disease is a chronic disease with acute flares. Transmural means with acute flares. Transmural means abscesses and fistulas.abscesses and fistulas.

Ulcerative ColitisUlcerative Colitis

Ulcerative ColitisUlcerative Colitis

PrevalencePrevalence– 15 per 100,000 people in U.S.15 per 100,000 people in U.S.

Slightly more common than crohn’sSlightly more common than crohn’s

– Bimodal distributionBimodal distribution 30’s and 70’s30’s and 70’s

Unlike crohn’s is Unlike crohn’s is curablecurable with with colectomycolectomy

SymptomsSymptoms Vary based on degree of mucosal inflammationVary based on degree of mucosal inflammation

– Bloody diarrheaBloody diarrhea– Cramping abdominal painCramping abdominal pain– TenesmusTenesmus

Acute flares and remissionAcute flares and remission Toxic megacolonToxic megacolon

– Feared complication of UCFeared complication of UC– Fever, leukocytosisFever, leukocytosis– Requires urgent colectomyRequires urgent colectomy

If patient has fistula, abscess, obstruction, If patient has fistula, abscess, obstruction, perianal disease it is crohn’s perianal disease it is crohn’s notnot ulcerative colitis ulcerative colitis

Symptoms relate to part of intestine involvedSymptoms relate to part of intestine involved– intraluminal = UCintraluminal = UC– intra and extraluminal=crohn’sintra and extraluminal=crohn’s

PathophysiologyPathophysiology Only effects the colonOnly effects the colon

– Terminal “backwash” ileitis often Terminal “backwash” ileitis often confused with crohn’sconfused with crohn’s

– Continuous involvement of rectum and Continuous involvement of rectum and coloncolon

Mucosal and submucosal onlyMucosal and submucosal only– No fistula or abscesses b/c not transmuralNo fistula or abscesses b/c not transmural– Crypt abscessesCrypt abscesses– PsuedopolypsPsuedopolyps– NO perianal diseaseNO perianal disease

Extraintestinal Extraintestinal manifestationsmanifestations

•40-60% of patients with primary sclerosing cholangitis have UC

•Colectomy does not change course of PSC

Endoscopic findingsEndoscopic findings

Mucosal ulceration, erythema and mucus

Severe colitis causing hematochezia

Radiology findingsRadiology findings

“Lead pipe” appearance on contrast enema due to loss of haustra

CT showing diffuse, mild inflammation of the sigmoid colon due to UC

Medical treatment for Medical treatment for Ulcerative ColitisUlcerative Colitis Maintenance of RemissionMaintenance of Remission

– SalicylatesSalicylates– CorticosteroidsCorticosteroids

TopicalTopical SystemicSystemic

– ImmunosuppressantsImmunosuppressants AzathioprineAzathioprine 6-MP6-MP CyclosporineCyclosporine MethotrexateMethotrexate Infliximab (Remicade)Infliximab (Remicade)

– Monitor for dysplasia/carcinomaMonitor for dysplasia/carcinoma EndoscopyEndoscopy

– Annually after 8 yearsAnnually after 8 years– Random biopsies 40-50 throughout colonRandom biopsies 40-50 throughout colon

Medical treatment for Medical treatment for Ulcerative ColitisUlcerative Colitis Acute flareAcute flare

– Systemic corticosteroidsSystemic corticosteroids– Bowel restBowel rest– IVF hydrationIVF hydration– Antibiotics (bacterial Antibiotics (bacterial

translocation/fulminate colitis)translocation/fulminate colitis)

Indications for surgical Indications for surgical management of management of ulcerative colitisulcerative colitis EmergentEmergent

– Fulminant colitis/toxic megacolonFulminant colitis/toxic megacolon– HemorrhageHemorrhage– Failure of medical managementFailure of medical management

Indications for surgical Indications for surgical management of management of ulcerative colitisulcerative colitis ElectiveElective

– Inability to tolerate medical therapyInability to tolerate medical therapy– Intractable disease despite maximal medical Intractable disease despite maximal medical

therapytherapy– Development of dysplasia/carcinomaDevelopment of dysplasia/carcinoma

Risk of malignancy increases with timeRisk of malignancy increases with time– 2% after 10 years2% after 10 years– 8% after 20 years8% after 20 years– 18% after 30 years18% after 30 years

– ANY dysplasia (mild or otherwise) is ANY dysplasia (mild or otherwise) is indication for total proctocolectomyindication for total proctocolectomy

Surgical treatment of Surgical treatment of ulcerative colitisulcerative colitis

EmergentEmergent– 3 stage3 stage

Total abdominal Total abdominal colectomy (leaves colectomy (leaves rectum in place to rectum in place to be removed later) be removed later) with end ileostomywith end ileostomy

Proctectomy Proctectomy (removal of (removal of remaining rectum) remaining rectum) and j-pouch and j-pouch creation) with loop creation) with loop ileostomyileostomy

Takedown of loop Takedown of loop ileostomyileostomy

Surgical treatment of Surgical treatment of ulcerative colitisulcerative colitis ElectiveElective

– 2 stage2 stage Proctocolectomy Proctocolectomy

(removal of entire (removal of entire colon and rectum) colon and rectum) with ileo-anal pouch with ileo-anal pouch anastomosis and anastomosis and protecting loop protecting loop ileostomyileostomy

Ileostomy takedown Ileostomy takedown 3-6 months later3-6 months later

Following surgery for Following surgery for ulcerative colitisulcerative colitis Tapering of steroids post-opTapering of steroids post-op Typically 6-8 bowel movements daily Typically 6-8 bowel movements daily

with j-pouchwith j-pouch– Most do not have night-time incontinenceMost do not have night-time incontinence

Anything less than total proctocolectomy Anything less than total proctocolectomy needs surveillance for dysplasianeeds surveillance for dysplasia

ComplicationsComplications– PouchitisPouchitis– Anastomotic strictureAnastomotic stricture– Bowel obstructions from adhesionsBowel obstructions from adhesions

Is it Is it Crohn’s or Ulcerative Crohn’s or Ulcerative Colitis?Colitis?

Crohn’s vs UC on Crohn’s vs UC on endoscopyendoscopy