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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
LOOK BEFORE YOU LEAP
LOOK BEFORE YOU LEAP
LOOK BEFORE YOU LEAP
LOOK BEFORE YOU LEAP
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
Difficult SB Crohn’sDifficult SB Crohn’s
• Duodenal diseaseDuodenal disease
• Multiple stricturesMultiple strictures
• Enterocutaneous fistulaEnterocutaneous fistula
DuodenalDuodenalCrohn’sCrohn’s
A few factsA few facts
• Rare - <5%Rare - <5%
• Differential diagnosis Differential diagnosis
• Rarely sole siteRarely sole site
• Often overshadowedOften overshadowed
Duodenum plus . . . .Duodenum plus . . . .
• D3 strictureD3 stricture
• Advanced ileal Advanced ileal diseasedisease
Clinical scenariosClinical scenarios
• ‘‘Peptic ulcer-like’Peptic ulcer-like’
• ObstructionObstruction
• FistulaFistula
Patterns of diseasePatterns of disease
**
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%
InvestigationInvestigation
• Barium studies Barium studies
• ScanningScanning
• EndoscopyEndoscopy
Conventional Ba mealConventional Ba meal
• Anatomical clarityAnatomical clarity
• Endoscopy neededEndoscopy needed
BaM in D3 obstructionBaM in D3 obstruction
• Poor viewPoor view
• No distal informationNo distal information
CT in D4 obstructionCT in D4 obstruction
EndoscopyEndoscopy
• Differential diagnosisDifferential diagnosis• DilatationDilatation
Treating obstructionTreating obstruction
• Balloon dilatationBalloon dilatation
• BypassBypass
• StrictureplastyStrictureplasty
Balloon dilatationBalloon dilatation
• May avoid surgeryMay avoid surgery
• Few dataFew data
• Distal diseaseDistal disease
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)
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
‘‘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
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
D2-transverse colic fistulaD2-transverse colic fistula
• Normal duodenumNormal duodenum
• Penetrating ulcersPenetrating ulcers
• Simple closure Simple closure
after colectomyafter colectomy
Multiple Multiple stricturesstrictures
Multiple stricturesMultiple strictures
• Failure to thriveFailure to thrive
• ObstructionObstruction
Multiple stricturesMultiple strictures
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 . . .
Multiple stricturesMultiple strictures
• Might surgery help?Might surgery help?
• If so, what surgery?If so, what surgery?– (Bypass) (Bypass)
– ResectionResection
– StrictureplastyStrictureplasty
Multiple stricturesMultiple strictures
Pros and cons of strictureplastyPros and cons of strictureplasty
• Bowel conservationBowel conservation
• SafetySafety
• Relapse rateRelapse rate
Multiple stricturesMultiple strictures
Recurrence avoidanceRecurrence avoidanceOxford, 1995
Multiple stricturesMultiple strictures
Recurrence avoidanceRecurrence avoidance
2006 meta analysis2006 meta analysisTekkis et al.
StrictureplastyStrictureplastyWhat’s available?What’s available?
StrictureplastyStrictureplastyWhat’s available?What’s available?
StrictureplastyStrictureplastyWhat’s available?What’s available?
What do th
ey achieve?
What do th
ey achieve?
StrictureplastyStrictureplastyWhat’s available?What’s available?
StrictureplastyStrictureplastyBeware the occult strictureBeware the occult stricture
StrictureplastyStrictureplastyPick ‘n’ Mix . . .Pick ‘n’ Mix . . .
Enterocutaneous Enterocutaneous fistulafistula
Enterocutaneous fistulaEnterocutaneous fistula
Surgery rarely avoided
Surgery rarely avoided
Avoiding re-operationAvoiding re-operation
Avoiding re-operationAvoiding re-operation
NONOUNEXPECTED UNEXPECTED
EXTRA EXTRA PROCEDURESPROCEDURES
Avoiding DISASTERAvoiding DISASTER
DON’T GO IN
TOO EARLY
DON’T GO IN
TOO EARLY
Avoiding DISASTERAvoiding DISASTER
DON’T GO IN
TOO EARLY
DON’T GO IN
TOO EARLY
Avoiding DISASTERAvoiding DISASTER
DON’T GO IN
TOO EARLY
DON’T GO IN
TOO EARLY
WAIT!!WAIT!!
Avoiding DISASTERAvoiding DISASTER
DON’T GO IN
TOO EARLY
DON’T GO IN
TOO EARLY
WAIT!!WAIT!!and PREPAREand PREPARE
Exclude distal obstructionExclude distal obstruction
Exclude septic collectionsExclude septic collections
Find the optimalFind the optimal entry siteentry site
Pre-operative preparation Pre-operative preparation
Avoiding re-operationAvoiding re-operation
• ROADMAPROADMAP
• Composite imageComposite image
• Pre-operate in headPre-operate in head
DIFFICULTDIFFICULTSMALL BOWEL SMALL BOWEL
CROHN’S DISEASECROHN’S DISEASE
John NorthoverJohn Northover
St Mark’s Hospital, LondonSt Mark’s Hospital, London