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Inflammatory Bowel Disease Dr. Hagit Tulchinsky, Proctology Unit, Surgery B Tel Aviv Sourasky Medical Center Epidemiology Developed countries More common in Jewish population (3-5 folds), whites Equal distribution between genders Bimodal age distribution: 15-35y, 50-70y Etiology-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-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-3 Host – defective mucosal barrier function NSAID`s exacerbate IBD Cigarette smoking: protective in UC, aggressive factor in Crohn`s d. Etiology- Summary These diseases are due to aberrant host response to environmental antigens in genetically susceptible individuals Pathology-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 Pathology-UC-2 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 Crohn`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 Crohn`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 Crohn`s disease-3 Microscopic appearance Patchy distribution 2/3 – noncaseating granulomas, Transmural chronic inflammation, Serositis, fibrous adhesions Deep ulcers into the muscle layers Cancer and dysplasia Increased risk in long standing disease Pathology-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 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 findings Reflect the severity of the disease Abdominal tenderness (left side) Abdominal distention Fever, tachycardia Proctitis- urgency, tenesmus, fecal incontinence Extraintestinal manifestations Peripheral arthritis, 15-20%, resolve after colectomy Ankylosing spondylitis Sacroiliitis Primary sclerosing cholangitis – more in UC, no resolution post op Surgery-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 surgery UC Intractability – most common Involvement of other organs Large bowel dysplasia/cancer Indications for elective surgery UC 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 surgery UC 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 surgery UC 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 surgery UC 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-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 anatomy Proctocolectomy Colectomy with ileorectal anastomosis Choice of Operation Elective treatment of choice Restorative proctocolectomy with ileal reservoir The ileal pouch anal anastomosis The 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 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 procedure Technique 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 incision Proctocolectomy The pouch procedure Technique Stage 1- The pouch operation J pouch Pouch joined to the anus Protective loop ileostomy ILEAL POUCH-ANAL ANASTOMOSIS The pouch procedure Technique Stage 2 – Closure of ileostomy Relatively minor procedure Cut around the ileostomy Bowel closed The hole in the abdomen closed The pouch procedure Results Early complications Obstruction Infection The pouch procedure Results Late complications Obstruction Pouchitis Defecation problems Anal skin soreness Pouch fistula The pouch procedure Results Function Frequency Urgency Continence Anti diarrheal medications The pouch procedure Results Quality of life 90% - better Failure Up to 15% Surgery Crohn`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 surgery Crohn`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 surgery Crohn`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 surgery 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 surgery Crohn`s disease Perforation Most are sealed Massive bleeding Rare – 1% of patients Principles of operative treatment 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 options 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 options Crohn`s disease Stricturoplasty - Small bowel strictures, fibrotic recurrence at ileocolic or ileoractal anastomosis - Not for colonic narrowing - Indications and contra indications - Technique STRICTUROPLASTY (HEINEKE-MIKULICZ) STRICTUROPLASTY (FINNEY) Thank You