Inflammatory Bowel Inflammatory Bowel DiseaseDisease

Dr. Hagit Tulchinsky, Proctology Unit, Surgery B

Tel Aviv Sourasky Medical Center

EpidemiologyEpidemiology

Developed countries More common in Jewish population (3-5 folds),

whites Equal distribution between genders Bimodal age distribution: 15-35y, 50-70y

Etiology-1Etiology-1

UC and Crohn`s – separate entities ? 10-15% of IBD - Indeterminate colitis 10% - diagnosis is changed Relatives – more likely to have the same disease as

the proband Cluster within families

Etiology-2Etiology-2

Genetic predisposition + environmental factors (dietary intake)

Complex genetic disorder UC - less significant genetic contribution than in

Crohn`s d. Susceptibility locus, IBD 1, on chromosome 16 Molecular evidence of 2 forms of Crohn`s pANCA – in most UC patients (75%)

Etiology-3Etiology-3

Host – defective mucosal barrier function NSAID`s exacerbate IBD Cigarette smoking: protective in UC, aggressive

factor in Crohn`s d.

Etiology- SummaryEtiology- Summary

These diseases are due to aberrant host response to environmental antigens in genetically susceptible individuals

Pathology-UC-1Pathology-UC-1

From rectum proximally Confined to colon and rectum Disease limited to the mucosa Macroscopic appearance

congested serosa

contracted and shortened bowel edema of the mesentery pseudopolyps 10% backwash ileities

Microscopic appearance

Only the mucosa is affected Cancer and dysplasia

3-5% develop cancer

Increased risk if extensive disease for at least 8

years

Surgery if low grade dysplasia

Pathology-UC-2Pathology-UC-2

Pathology Pathology Crohn`s disease-1Crohn`s disease-1

May affect any part of the intestinal tract Usually affects the terminal ileum and cecum Small bowel alone – 1/3 Colon alone – 1/3 Perianal region or upper GI tract alone – less

common

Pathology Pathology Crohn`s disease-2Crohn`s disease-2

Macroscopic appearance Skip lesions

Segmental colitis

Stenosis of terminal ileum

Anal lesions in 75%

Wrapping of mesenteric fat

Thickened wall irregularly

Thickened mesentery

Pathology Pathology Crohn`s disease-3Crohn`s disease-3

Microscopic appearance Patchy distribution 2/3 – noncaseating granulomas, Transmural chronic inflammation, Serositis, fibrous adhesions Deep ulcers into the muscle layersCancer and dysplasia Increased risk in long standing disease

Pathology-SummeryPathology-Summery

Pathologic features – more usually seen in chronic stages of the disease

Cardinal feature of Crohn`s d. - patchiness The presence of small bowel disease should

exclude UC High or complex perianal fistula / anal ulceration

– more likely Crohn`s d. Crypt distortion – characteristic of UC Granulomas are less specific

Clinical findingsClinical findings

Diarrhea, mucous discharge Rectal bleeding- more UC Obstructive symptoms- more Crohn’s d. Anal/perianal d.- more Crohn’s d. Loss of body weight Anemia

Physical findingsPhysical findings

Reflect the severity of the disease Abdominal tenderness (left side) Abdominal distention Fever, tachycardia Proctitis- urgency, tenesmus, fecal incontinence

Extraintestinal manifestationsExtraintestinal manifestations

Peripheral arthritis, 15-20%, resolve after colectomy Ankylosing spondylitis Sacroiliitis Primary sclerosing cholangitis – more in UC, no

resolution post op

Surgery-UCSurgery-UC

20-45% eventually undergo surgery Indications – elective / emergency Pre op. management:

- Correct hypovolemia + electrolytes

- Correct anemia

- If on steroids – Hydrocortisone I.V.

- Counseling and education on the outcome

- Severe malnutrition – TPN

- Prepare as for colon surgery

Indications for elective surgeryIndications for elective surgeryUCUC

Intractability – most common Involvement of other organs Large bowel dysplasia/cancer

Indications for elective surgeryIndications for elective surgeryUCUC

Intractability Failure of medical therapy Chronic complications of the disease Debilitating symptoms Poor nutrition Impaired quality of life Anemia Hypoproteinemia Children- failure to growth Side effects

Indications for elective surgeryIndications for elective surgeryUCUC

Presence and risk of cancer When to consider prophylactic surgery/close

surveillance program? Extensive and long standing colitis Onset at childhood/teenage + generalized colitis +10 or more yrs of disease – 2% will develop cancer each year PSC Dysplasia

Indications for elective surgeryIndications for elective surgeryUCUC

Debilitating extra intestinal manifestations

May improve after surgery

Cutaneouos, peripheral arthicular, ocular, hematological,vascular

Ankylosing spondilitis and rheumatoid arthritis will not regress

PSC may progress to cirrhosis or cholangio ca. after surgery

Indications for emergency surgeryIndications for emergency surgeryUCUC

Fulminant colitis

Tachycardia, fever, WBC > 10,500, low albumin

First – aggressive conservative treatment

Failure – surgery

Goal – operate before colonic perforation

Toxic megacolon Pain, fever, toxicity, abdominal tenderness and distention,

transverse colon >7cm

Perforation, hemorrhage and obstruction

Choice of Operation-UCChoice of Operation-UC

Restorative proctocolectomy Treatment of choice if elective CI – Crohn`s, incompetent sphincter, cancer in distal rectum Proctectomy with continent ileostomy Brooke ileostomy, poor sphincter Proctectomy with Brooke ileostomy Colectomy and ileorectal anastomosis Rarely used today only if relative rectum sparing, young males

Normal anatomyNormal anatomy

ProctocolectomyProctocolectomy

Colectomy with ileorectal Colectomy with ileorectal anastomosisanastomosis

Choice of OperationChoice of Operation

Elective treatment of choice

Restorative proctocolectomy with ileal reservoir

The ileal pouch anal anastomosis

The pouch procedureThe pouch procedure

Removes all of the colon and rectum Preserves the anal canal Aim – to avoid permanent ileostomy The decision is up to the patient Information on the pros and cons

The pouch procedureThe pouch procedure

WHO IS ELIGIBLE ? Ulcerative colitis and not Crohn`s disease Patients who had no operation Patients who had a colectomy with ileostomy or

ileorectal anastomosis Good anal sphincter control

The pouch procedureThe pouch procedure TechniqueTechnique

Stage 1- The pouch operation

Abdomen opened Colon and rectum are freed Rectum is cut above the anal sphincter Small bowel and anus left in place

Abdominal incisionAbdominal incision

ProctocolectomyProctocolectomy

The pouch procedureThe pouch procedure TechniqueTechnique

Stage 1- The pouch operation

J pouch Pouch joined to the anus Protective loop ileostomy

ILEAL POUCH-ANAL ILEAL POUCH-ANAL ANASTOMOSISANASTOMOSIS

The pouch procedureThe pouch procedure TechniqueTechnique

Stage 2 – Closure of ileostomy

Relatively minor procedure Cut around the ileostomy Bowel closed The hole in the abdomen closed

The pouch procedureThe pouch procedure ResultsResults

Early complications Obstruction Infection

The pouch procedureThe pouch procedure ResultsResults

Late complications Obstruction Pouchitis Defecation problems Anal skin soreness Pouch fistula

The pouch procedureThe pouch procedure ResultsResults

Function Frequency Urgency Continence Anti diarrheal medications

The pouch procedureThe pouch procedure ResultsResults

Quality of life

90% - better

Failure

Up to 15%

SurgerySurgeryCrohn`s diseaseCrohn`s disease

Typical presenting symptoms: Abdominal pain, diarrhea, weight loss Reserved for patients whose quality of life is

significantly impaired despite appropriate medical therapy or after disease associated complications develop

The probability of undergoing surgery is 78-90% after 20 and 30 yrs, respectively

Elective / emergent indications

Indications for elective surgeryIndications for elective surgeryCrohn`s diseaseCrohn`s disease

Fistula ± abscess

The most common indication

Different types of fistula

Rarely heal with corticosteroids

6-MP will promote closure in 30-40%

Obstruction

Chronic/acute

Single/multiple sites of stricture

Indications for elective surgeryIndications for elective surgeryCrohn`s diseaseCrohn`s disease

Failed medical therapy

Incomplete response

Maintenance medications cannot be stopped

Significant side effects

Intra abdominal abscess/fistula Carcinoma Growth retardation

15-30% of children with Crohn`s

Op. is indicated only in the pre pubertal child

Indications for emergency surgeryIndications for emergency surgery Crohn`s disease Crohn`s disease

Fulminant colitis and Toxic megacolon

Acute flare and at least 2 of the following: Tachycardia >100 , fever >38.6, WBC > 10,500, albumin<3 Initial therapy –correct physiological deficits,

high dose steroids or immunosuppresants, bowel rest, antibiotics

Any worsening during the initial 48h - surgery Free perforation, massive hemorrhage, peritonitis, septic

shock – emergent op.

Indications for emergency surgeryIndications for emergency surgery Crohn`s disease Crohn`s disease

Perforation Most are sealedMassive bleeding Rare – 1% of patients

Principles of operative treatmentPrinciples of operative treatment Crohn`s disease Crohn`s disease

PALLIATIVE, CONSERVATISM

Minimal procedure with maximal effect Mechanical and antibiotic preparation I.V. Steroids Stop immunosuppressive therapy Correction of deficits Stoma marking

Operative optionsOperative options Crohn`s disease Crohn`s disease

Bypass

Rarely recommended – high recurrence rate and malignancy risk

Resection

Macroscopic healthy margins

Anastomosis

Stapled or handsewn

Same principles as for any anastomosis

Operative optionsOperative options Crohn`s disease Crohn`s disease

Stricturoplasty - Small bowel strictures, fibrotic recurrence at

ileocolic or ileoractal anastomosis

- Not for colonic narrowing

- Indications and contra indications

- Technique

STRICTUROPLASTY STRICTUROPLASTY (HEINEKE-MIKULICZ)(HEINEKE-MIKULICZ)

STRICTUROPLASTY STRICTUROPLASTY (FINNEY)(FINNEY)

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