General Principles of Medical and Surgical

Management of Inflammatory Bowel Disease

Jeraldine S. Orlina

Colorectal Conference

December 22, 2005

Medical Therapy of Ulcerative Colitis

5-Aminosalicyclic acid agents Corticosteroids Cyclosporine 6-Mercaptopurine Azathioprine

5-Aminosalicylic Acid Agents

Sulfasalazine

- 5-ASA linked to sulfapyridine by an azo bond

- poorly absorbed in upper GI tract

- principle use to maintain remission

                                                                                                  

Operative Indications

Failure of medical therapy Obstruction Fistula or abscess Hemorrhage Growth retardation (in pediatric population) Perforation of carcinoma Extraintestinal manifestations

Preparation of the Patient

Endoscopic and Radiologic studies Correction of dehydration, electrolyte

deficiencies, coagulation deficits, and anemia

Optimization of comorbid conditions Nutritional optimization Pre-op marking for stoma (if needed) Bowel prep

Preparation of patient

Withdrawal of immunosuppressives Perioperative antibiotics Stress dose steroids DVT prophylaxis

Strategic Planning for Surgery

Midline incision to preserve potential stoma sites

Preservation of small bowel Resection margins—extended resection

margins are unnecessary Use of temporary stoma

Management of Small Bowel Crohn’s Diesease

Chronic obstruction (35%) Internal fistulas (30%) Intractability (22%) Abscess formation (11%)

Types of Operations

Small bowel resection Multiple small bowel resections (with

enteroenterorostomy, diversion, or both) Bypass Strictureplasty Balloon dilatation

Resection

Most common surgical procedure Wide resection unnecessary Division of inflamed mesentery

Indications for Strictureplasty

Diffuse involvement of small bowel with multiple strictures

Strictures in a pt who has undergone prev major resection of small bowel

Rapid recurrence of disease manifested as obstruction

Stricture in pt with short bowel syndrome Nonphlegmonous fibrotic stricture

Relative Contraindications for Stictureplasty

Free or contained perforation of the small bowel Phlegmonous inflammation, internal fistula, or

external fistula involving the affected site Multiple strictures within a short segment Stricture in close proximity to a site chosen for

resection Colonic strictures Hypoalbuminemia

Heineke-Mikulicz Strictureplasty

Finney Strictureplasty

Side-to-side isoperistaltic strictureplasty

Stapled Strictureplasty

Complications

Hemorrhage form suture line Restricture at strictureplasty site Fistula/Abscess/Leak Small bowel adenocarcinoma

Take Home Points

Conservative Management Preservation of small bowel