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DIFFICULT SMALL BOWEL CROHN’S DISEASE

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DIFFICULT SMALL BOWEL CROHN’S DISEASE. John Northover St Mark’s Hospital, London. LOOK BEFORE YOU LEAP. LOOK BEFORE YOU LEAP. Causes of intestinal failure St Mark’s & Hope, 1999-2002. Difficult SB Crohn’s. Duodenal disease Multiple strictures Enterocutaneous fistula. Duodenal Crohn’s. - PowerPoint PPT Presentation
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DIFFICULT DIFFICULT SMALL BOWEL SMALL BOWEL CROHN’S DISEASE CROHN’S DISEASE John Northover John Northover St Mark’s Hospital, St Mark’s Hospital, London London
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Page 1: DIFFICULT SMALL BOWEL  CROHN’S DISEASE

DIFFICULTDIFFICULTSMALL BOWEL SMALL BOWEL

CROHN’S DISEASECROHN’S DISEASE

John NorthoverJohn Northover

St Mark’s Hospital, LondonSt Mark’s Hospital, London

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LOOK BEFORE YOU LEAP

LOOK BEFORE YOU LEAP

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LOOK BEFORE YOU LEAP

LOOK BEFORE YOU LEAP

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Causes of intestinal failureCauses of intestinal failureSt Mark’s & Hope, 1999-2002St Mark’s & Hope, 1999-2002

0

10

20

30

40

50

60

70%

pat

ient

s

Hope

St Mark's

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Difficult SB Crohn’sDifficult SB Crohn’s

• Duodenal diseaseDuodenal disease

• Multiple stricturesMultiple strictures

• Enterocutaneous fistulaEnterocutaneous fistula

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DuodenalDuodenalCrohn’sCrohn’s

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A few factsA few facts

• Rare - <5%Rare - <5%

• Differential diagnosis Differential diagnosis

• Rarely sole siteRarely sole site

• Often overshadowedOften overshadowed

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Duodenum plus . . . .Duodenum plus . . . .

• D3 strictureD3 stricture

• Advanced ileal Advanced ileal diseasedisease

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Clinical scenariosClinical scenarios

• ‘‘Peptic ulcer-like’Peptic ulcer-like’

• ObstructionObstruction

• FistulaFistula

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Patterns of diseasePatterns of disease

**

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SymptomsSymptoms

• ‘‘Peptic ulcer’ pain Peptic ulcer’ pain 70%70%

• Vomiting Vomiting 50%50%

• Weight loss Weight loss 26%26%

• Diarrhoea Diarrhoea 22%22%

• Bleeding Bleeding 7%7%

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InvestigationInvestigation

• Barium studies Barium studies

• ScanningScanning

• EndoscopyEndoscopy

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Conventional Ba mealConventional Ba meal

• Anatomical clarityAnatomical clarity

• Endoscopy neededEndoscopy needed

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BaM in D3 obstructionBaM in D3 obstruction

• Poor viewPoor view

• No distal informationNo distal information

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CT in D4 obstructionCT in D4 obstruction

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EndoscopyEndoscopy

• Differential diagnosisDifferential diagnosis• DilatationDilatation

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Treating obstructionTreating obstruction

• Balloon dilatationBalloon dilatation

• BypassBypass

• StrictureplastyStrictureplasty

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Balloon dilatationBalloon dilatation

• May avoid surgeryMay avoid surgery

• Few dataFew data

• Distal diseaseDistal disease

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BypassBypass

• Check for distal diseaseCheck for distal disease• ? need for vagotomy? need for vagotomy

– ““4/6 without4/6 withoutre-operation”re-operation” (Cleveland, (Cleveland,

‘83)‘83)

– ““Most re-do surgery after Vx; risk Most re-do surgery after Vx; risk of diarrhoea”of diarrhoea” (Lahey, ‘89)(Lahey, ‘89)

– ““Remains controversial”Remains controversial” (B’ham, ‘99)(B’ham, ‘99)

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StrictureplastyStrictureplasty

• 13 patients (10 primary)13 patients (10 primary)

• 2/10 leaked2/10 leaked

• 6 re-strictured6 re-stricturedsurgerysurgery

• Overall 9/13 re-operatedOverall 9/13 re-operatedBirmingham, 1999Birmingham, 1999

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‘‘Plasty v BypassPlasty v Bypass

• Historical and parallel comparisonHistorical and parallel comparison

• Bypass 21; strictureplasty 13Bypass 21; strictureplasty 13

• Same:Same:– Complications (2/21; 2/13)Complications (2/21; 2/13)

– RecurrenceRecurrenceRe-op. (1/21; 1/13)Re-op. (1/21; 1/13)

Cleveland Clinic, 1999Cleveland Clinic, 1999

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Fistulating duodenal Crohn’sFistulating duodenal Crohn’s

• Usually secondaryUsually secondary

• To colon or terminal SBTo colon or terminal SB

• Duodenocutaneous Duodenocutaneous rarerare

• Most OK for oversewMost OK for oversew

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D2-transverse colic fistulaD2-transverse colic fistula

• Normal duodenumNormal duodenum

• Penetrating ulcersPenetrating ulcers

• Simple closure Simple closure

after colectomyafter colectomy

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Multiple Multiple stricturesstrictures

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Multiple stricturesMultiple strictures

• Failure to thriveFailure to thrive

• ObstructionObstruction

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Multiple stricturesMultiple strictures

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Multiple stricturesMultiple strictures

• What trouble are they?What trouble are they?

• Other modalities?Other modalities?

• Previous surgery?Previous surgery?

• Is there a ‘dominant’ stricture?Is there a ‘dominant’ stricture?

• AND ONLY THEN . . . AND ONLY THEN . . .

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Multiple stricturesMultiple strictures

• Might surgery help?Might surgery help?

• If so, what surgery?If so, what surgery?– (Bypass) (Bypass)

– ResectionResection

– StrictureplastyStrictureplasty

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Multiple stricturesMultiple strictures

Pros and cons of strictureplastyPros and cons of strictureplasty

• Bowel conservationBowel conservation

• SafetySafety

• Relapse rateRelapse rate

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Multiple stricturesMultiple strictures

Recurrence avoidanceRecurrence avoidanceOxford, 1995

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Multiple stricturesMultiple strictures

Recurrence avoidanceRecurrence avoidance

2006 meta analysis2006 meta analysisTekkis et al.

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StrictureplastyStrictureplastyWhat’s available?What’s available?

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StrictureplastyStrictureplastyWhat’s available?What’s available?

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StrictureplastyStrictureplastyWhat’s available?What’s available?

What do th

ey achieve?

What do th

ey achieve?

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StrictureplastyStrictureplastyWhat’s available?What’s available?

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StrictureplastyStrictureplastyBeware the occult strictureBeware the occult stricture

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StrictureplastyStrictureplastyPick ‘n’ Mix . . .Pick ‘n’ Mix . . .

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Enterocutaneous Enterocutaneous fistulafistula

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Enterocutaneous fistulaEnterocutaneous fistula

Surgery rarely avoided

Surgery rarely avoided

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Avoiding re-operationAvoiding re-operation

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Avoiding re-operationAvoiding re-operation

NONOUNEXPECTED UNEXPECTED

EXTRA EXTRA PROCEDURESPROCEDURES

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Avoiding DISASTERAvoiding DISASTER

DON’T GO IN

TOO EARLY

DON’T GO IN

TOO EARLY

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Avoiding DISASTERAvoiding DISASTER

DON’T GO IN

TOO EARLY

DON’T GO IN

TOO EARLY

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Avoiding DISASTERAvoiding DISASTER

DON’T GO IN

TOO EARLY

DON’T GO IN

TOO EARLY

WAIT!!WAIT!!

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Avoiding DISASTERAvoiding DISASTER

DON’T GO IN

TOO EARLY

DON’T GO IN

TOO EARLY

WAIT!!WAIT!!and PREPAREand PREPARE

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Exclude distal obstructionExclude distal obstruction

Exclude septic collectionsExclude septic collections

Find the optimalFind the optimal entry siteentry site

Pre-operative preparation Pre-operative preparation

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Avoiding re-operationAvoiding re-operation

• ROADMAPROADMAP

• Composite imageComposite image

• Pre-operate in headPre-operate in head

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DIFFICULTDIFFICULTSMALL BOWEL SMALL BOWEL

CROHN’S DISEASECROHN’S DISEASE

John NorthoverJohn Northover

St Mark’s Hospital, LondonSt Mark’s Hospital, London


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