MEDICAL PRESENTATION

Operative management of

Crohn Disease

Jayavignesh Sekar PGY1

INDEX

1. Anatomy

2. Epidemiology

3. Clinical presentation

4. Diagnosis

5. Non Operative Rx

6. Operative Rx

7. Followup

Born in NY 1884Died at New Milford, CT 1983

Crohn disease is a chronic, transmural inflammatory disease of the gastrointestinal tract for which the definitive cause is unknown, although a combination of genetic and environmental factors has been implicated.

- Dr Burrill Bernard Crohn MD

Anatomy

• Terminal ileum is the most common location of Crohn disease, 15% to 20% in the Colon

• Perianal disease, including anal fissures, fistulas, skin tags, strictures, and ulceration- 30% in the terminal ileal disease and >50% with colonic involvement.

• Rare in mouth, esophagus, stomach, duodenum, and appendix without concomitant intestine involvement.

Pathological Features

• Gross pathologic features

-creeping fat -skip areas of involvement -thickened mesentery -enlarged lymph nodes -long, deep, linear, aphthous ulcers in the mucosa; -ulcerations and cobblestoning.

• Microscopic/histologic - transmural inflammatory infiltrates through the mucosa and submucosa with noncaseating granulomas and Langerhans giant cells.

Epidemiology

Geography, Age and Gender

- The prevalence of IBD in Western countries is approximately 0.5% of the general population. 50 of 100,000 population for crohn. - Bimodal distribution of cases, with the majority presenting between the ages of 15 to 25 years and a second peak between the ages of 55 to 65 years. - Male = Female

Etiology

• Unknown

• Combination of both genetic and environmental - Smoking & infection (Mycobacterium paratuberculosis and entero adherent Escherichia coli)

• Dietary pattern

• Genetic- NOD2/CARD15, IL23R, and ATG16L1

• Familial - 30x in siblings

15x in First degree relatives

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Presentation

• Episodic
• Complications
• Extra Intestinal Manifestations

• Anemia
• osteoporosis
• Joints
• Liver
• Eyes
• Skin

Symptoms

Recurrent

• Abdominal pain
• Diarrhea
• Weight loss.

• or just isolated perianal disease.

Quiescent

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Complications

Extraintestinal

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Diagnosis

• H&P, Imaging, laboratory values, and colonoscopy and biopsy.

• MRI may be superior in differentiating active inflammatory strictures from chronic fibrostenotic strictures as well as intestinal wall enhancement that correlates with active disease.

Vienna Classification

• Age at diagnosis (less than or greater than 40 years)

• Behavior (inflammatory, stricturing, or penetrating)

• Location (terminal ileum, colon, ileocolonic, upper gastrointestinal tract, anorectal)

Medical management

• Corticosteroids

• Tumor necrosis factor alpha antagonists such as infliximab, adalimumab, and certolizumab

• Aminosalicylates such as sulfasalazine and mesalamine

• Immunosuppressives such as azathioprine, 6-mercaptopurine, methotrexate, and tacrolimus

• Novel agents such as vedolizumab and ustekinumabA

Operative Treatment

Surgery for Crohn disease is not curative, and therefore it is necessary to minimize the extent of small bowel resection.

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Strictures

Obstruction is the most common indication for surgery

• Endoscopic Dilatation
• Stricturoplasty - Heineke Mikulicz, Finney,
• Segmental resection

Small Bowel Strictures

Colonic Strictures

• Endoscopic dilatation or resection, but no stricturoplasty

Fistulas

• Up to 35% of patients with Crohn disease develop intestinal fistulas.

• Most involve other small bowel, colon, abdominal wall and skin, or other surrounding viscera (bladder, gynecologic structures)

• May respond to anticytokine therapy, if not - resection and primary repair of involved organ.

Perforation and abscess

Perforation

Abscess

• Percutaneous drain placement, antibiotics, and interval resection of the involved bowel segment with a delay of 4 to 6 weeks.

• If left unresected, at least 30% will develop recurrent abscesses.

• Penetrating disease is usually associated with localized abscess but can occasionally result in free perforation into the abdominal cavity.

• Minimal contamination --> Resection and Primary Anastamosis

• Generalized peritonitis -diverting enterostomy with delayed reconstruction.

Bleeding

• Most bleeding associated with Crohn disease is chronic blood loss and its associated anemia. However, life-threatening hemorrhage may occur with colonic disease

• Arteriography, CT angiography, or tagged red blood cell scanning

• Duodenal bleeding- endoscopic intervention

Cancer

• IIncreased incidence of cancer in long-standing Crohn disease, particularly colon cancer.- upto 7%

• Patients with chronic active disease require persistent surveillance.

• The presence of high-grade dysplasia or inability to rule out a malignancy is an indication for colectomy.

Toxic Colitis

• Patients present with high fever, severe abdominal pain and distention, hemodynamic instability, and leukocytosis.

• If peritonitis is present, this mandates emergent surgery. Otherwise, aggressive nonoperative management and serial abdominal examinations may be appropriate for 24 to 36 hours, with surgery necessary if there is no improvement.

• The radiographic presence of a “megacolon” is not mandatory for the diagnosis of toxic colitis but is often seen. This syndrome mandates emergent total abdominal colectomy with end ileostomy and occurs more commonly in ulcerative colitis.

Failure of Medical Management

• Inadequate control of symptoms,

• side effects of medications that may prohibit their use, and

• patient noncompliance with medical management.

CHILDREN WITH CROHN dISEASE

• systemic complications such growth retardation- may benefit from surgical resection.

Type of Operative interventions

• Laparoscopic Surgery
• Segmental Resection
• Subtotal Colectomy
• Proctectomy or total proctocolectomy with end (Brooke) ileostomy.

Segmental resectioN

• The goal is to remove only the grossly inflamed tissue, even if the adjacent tissue is clearly diseased. Frozen sections are an unreliable way to identify microscopic disease and are not predictive of postoperative recurrence.

• The decision to use primary anastomosis versus diversion depends on many factors, including the extent of intra-abdominal contamination, nutritional status, steroid use, and overall clinical stability.

• The optimal type of anastomosis (stapled vs hand-sewn, side-to-side vs end-to-end) is an area of ongoing research and debate.

Subtotal colectomy

• This is indicated for patients with sepsis due to colonic Crohn disease requiring emergency operation, in which case an end ileostomy is indicated.

• Also, this may be indicated for patients with multiple sites of colonic Crohn disease. Ileorectal anastomosis may be appropriate if the bowel appears healthy.

Proctectomy or total proctocolectomy with end (Brooke) ileostomy

• In patients with extensive perianal and rectal disease that is refractory to medical management, removal of the rectum (and possibly the entire colon, based on disease distribution) can aid in symptom control.

• Proctectomy is very rarely indicated in the emergent setting because of its high risk of complications.

fOLLOWUP AND RECURRENCE

• Endoscopic recurrence can be as high as 80% at 1 year after resection for Crohn colitis.

• Long-standing Crohn disease is associated with significant risk of cancer of the small intestine and colon

• Surveillance should start 8 years after disease diagnosis or at the time of diagnosis of PSC and be performed every 1 to 3 years. A random biopsy protocol mandates four biopsies every 10 cm from the cecum to the rectum.

• Patients with a Hartmann pouch and residual rectum should undergo surveillance of the rectum every 1 to 3 years.

• There is an increased risk of squamous cell carcinoma of the vulva and anal canal and Hodgkin and non-Hodgkin lymphomas in patients using immunomodulators for medical treatment.

Thanks!