Rob Padwick MRCS27th July 2011
CHALLENGES IN SURGICAL
MANAGEMENT OF INFLAMMATORY
BOWEL DISEASE
Aims
Management of severe (fulminant) colitis
Crohn’s disease
Prevalence 0.15% Unknown Aetiology;
Familial/Genetic Smoking REDUCES risk Immunological response
Affects Large Bowel mucosa ONLY Extra GI manifestations – eyes,
joints, skin, liver and biliary tree
ULCERATIVE COLITIS (UC)
ACUTE COMPLICATIONS OF UC
1. Acute severe (fulminating) colitis
2. Toxic megacolon
3. Perforation / Abscess
4. Bleeding
LONG-TERM COMPLICATIONS OF UC
1. Strictures
2. Recurrent Acute Attacks
3. Steroid Dependence
4. Colorectal Cancer
ACUTE SEVERE ULCERATIVE COLITIS
History and examination
• Bloody diarrhoea with mucus
• Urgency, abdo cramps
• Tachycardia, dehydration, pyrexia, peritonism,
• PR blood / mucus
ACUTE SEVERE ULCERATIVE COLITIS
Investigations• U&E
• FBC - WCC, Hb
• LFT’s – Albumin
• INR
• CRP
• ABG
• AXR, Erect CxR, CT
• Stool culture
• Unprepared FOS with minimal insufflation
- Confluent ulceration, erythema, contact bleeding
ACUTE SEVERE ULCERATIVE COLITIS
TREATMENT
1. Resuscitation – give blood, correct coagulopathy
correct metabolic derangement
2. Medical
Steroids• IV Hydrocortisone 100mg qds• 5 days if responding then oral steroids• Prednisolone 40mg o.d.
ACUTE SEVERE ULCERATIVE COLITIS
TREATMENT
2. Medical (cont.)
Steroids
Azathioprine
• Purine analogue immunosuppressant
• Steroid sparing
ACUTE SEVERE ULCERATIVE COLITIS
TREATMENT
2. Medical (cont.)
Steroids
Azathioprine
5-ASA
• Little / no role in acute setting
ACUTE SEVERE ULCERATIVE COLITIS
TREATMENT
2. Medical (cont.)Steroids
AzathioprineSalicylatesOther• PPI• Antibiotics• DVT prophylaxis
ACUTE SEVERE ULCERATIVE COLITIS
TREATMENT
2. Medical (cont.)
Cyclosporin
• Immunosuppressant
• Steroid failures at 5 days
• Remission in 50%
• Reduces need for emergency surgery
MEDICAL MANAGEMENT SUMMARY
The Oxford criteria the five day rule Truelove & Jewell 1974
Azathioprine maintenance of remission
Cyclosporin induction of remission McCormack G
2002
MEDICAL MANAGEMENT CHALLENGES
Uncertain end points
Masked sepsis
Late relapse
ACUTE FULMINATING COLITIS (UC)
TREATMENT
3. Surgical management
• Failure of medical at 5 days (25-50%)
• Toxic megacolon
• Perforation
• Bleeding
OPERATION
1. Sub-total colectomy
• Procedure of choice in the ill patient
• Preserve rectal stump
• Potential for Ileoanal pouch later
(IPAA)
2. Alternative operations
• Panproctocolectomy and end ileostomy
Postoperative management
• Wean steroids
• Monitor stump (e.g.proctitis)
• Monitor/treat sepsis
• Counseling via Multi-Disciplinary Team
TOXIC MEGACOLON
• ~45% mortality
• Surgery
• Non-resolution
• Impending or active perforation
PERFORATION
• More common in UC than Crohn’s
• Greatest risk is with first episode
• Especially splenic flexure, sigmoid colon
• Beware lack of signs!
HAEMORRHAGE
• Massive bleeding unusual
• 0-10%
• Colectomy is surgical procedure of choice
Risk increases with duration of disease; 2% at 10 years 8% at 20 years 18% at 30 years (Eaden et al 2001) Higher in severe colitis – 19x general population (Chambers
et al 2005) Colonoscopic Surveillance;
Colonoscopy at 10 years after diagnosis Follow-up according to risk stratification (NICE 2011) Dysplasia or malignancy on biopsy – proceed to total
colectomy
UC AND COLORECTAL CANCER
Crohn’s disease
Crohn’s disease
•Described in 1932 by Burrill Bernard Crohn
•Prevalence 0.07%
•Can affect the WHOLE GI TRACT
•Ileocaecal region ~50%
•15-40 years old
•Extra GI Manifestations – Eyes, Skin, Joints, Liver
Aetiology
•Largely unknown
•2-4x as common in smokers
•Genes – Chromosomes 3, 7, 12, HLA B27
•Family history
•Infective agents – Measles, Mumps, TB
Pathological features
•Transmural inflammation
•Fissures
•Non-caseating granulomas
•Skip lesions
Clinical features
•Diarrhoea
•Crampy Abdominal pain
•Weight loss
•Fever
•Perianal sepsis
•PR Bleeding
ACUTE COMPLICATIONS ININTESTINAL CROHN’S DISEASE
Investigation
• Haematology, biochemistry
• AXR, CxR
• Stool Culture
• Contrast study / CT
• MRI enteroclysis
1. Aims
• Palliate symptoms
• Control infection
• Correct nutrition
There is NO CURE !
TREATMENT
1. Medical
• Salicylates
• Azathioprine
• Steroids
• Biological agents (e.g. infliximab)
2 Surgical
TREATMENT
• Required in 75% of cases
• Indications;
• Failed medical treatment
• Stricture / Obstruction
• Abscess
• Fistulae
• Bleeding
SURGERY IN INTESTINALCROHN’S DISEASE
1. Stricturoplasty
• Avoids resection
• All strictures < 2cm
2. Limited bowel resection
SURGERY IN INTESTINALCROHN’S DISEASE
PERIANAL DISEASE
GENERAL
• > 50%
• Fissures
• Abscess
• Fistulae
• May be multiple and complex
PERIANAL DISEASE
FISTULAE
• Control sepsis
• Define and eradicate tracts
• Preserve sphincter function
Vagina Anus
CROHN’S AND COLORECTAL CANCER
•2-3x increased risk of colorectal cancer in
Crohn’s Disease (Bernstein et al 2001)
•Standard resection as opposed to total
colectomy
A 25 year old man presented with several months history of intermittent colicky abdominal pain. He noted some looseness of bowel movements during the past 6 months. He has lost about 1 stone in weight. Physical examination revealed a thin and young man. His temperature was normal. There was fullness in the RIF. Bowel sounds appeared to be hyperactive. PR examination was normal.
Na: 129 Hb: 13.1K: 2.9 WCC: 16Urea: 15 Platelet: 600
Creatinine: 250 CRP: 200a) State the likely diagnosis (1)
Acute Terminal Ileal Crohn’s Disease
b) Describe the obvious pathological feature of this disease shown in the picture above? (1 mark)Fat wrappingc) What are the radiological features of this disease? (2 marks)Any two of; Cobblestoning, pseudopolyps, skip lesions, stricturing, pseudodiverticulaed) What are the appropriate medical therapy for this disease (2 marks)Any two of; Salicylates, azathioprine, steroids, biologicals (e.g. infliximab)e) What are the indications for surgical intervention? (2 marks)Any two of; Failed Medical Therapy, Sricturing, Obstruction, Abscess, Fistulae, Bleedinge) What is Infliximab? (1 mark) Biological Agent - Anti-TNFa
Air under the diaphragm
Wrigler’s Sign