Inflammatory Bowel Disease RTC 10/30/09

October 30, 1735 2nd President of the United States, John Adams, was born. Prior to becoming president he served 2 terms as Vice President under George Washington. If we do not lay out ourselves in the service of mankind whom should we serve?

Objectives Review of pathology and clinical characteristics of Crohn s disease and Ulcerative Colitis Discuss common medical management strategies Understand surgical evaluation of patients with inflammatory bowel disease Crohn s disease Fulminant Ulcerative Colitis Understand indications for surgical treatment and rationale for specific procedures

CROHN S DISEASE ULCERATIVE COLITIS Thickened Wall/Mesentery +4 0 Creeping fat +4 0 Segmental disease +4 0 Transmural +4 0 Granulomas present +3 0 Bleeding per rectum +1 +3 Diarrhea +3 +3 Obstruction +3 +1 Anal/Peri-anal Disease +4 Rare Small Bowel Disease +4 0 Malignancy Risk +3 +2 GROSS MICROSCOPIC CLINICAL FEATURES

CROHN S DISEASE ULCERATIVE COLITIS Distribution Discontinuous Continuous Rectal Disease +1 +4 Longitudinal Ulcers +4 0 Aphthous Ulcers +4 0 Cobblestoning +4 0 Friability +1 +4 Pseudopolyps +2 +2 COLONOSCOPIC

Ulcerative colitis Fulminant

ulcerative colitis Criteria for evaluating severity of UC Variable Mild Disease Severe Disease Fulminant Disease Stools <4/day >6/day >10/day Blood in stool Intermittent Frequent Continuous Temperature Normal >37.5 >37.5 Pulse Normal >90 >90 Hgb Normal <75% normal Transfusion required ESR <30 >30 >30 Xray Features --- Air, edematous wall Dilatation Clinical Signs --- Tenderness Tenderness/Distension

Clinical evaluation History and Physical Duration of symptoms, medical therapy, etc. Labwork CBC, electrolytes, nutrition labs Stool for c.difficile, e.coli, CMV Imaging Plain films (abdomen; CXR) CT scan Endoscopy - diagnostic

Medical management Induction of remission: Corticosteroids/Cyclosporine I.V. Corticosteroid Therapy Response rate ~50-60% when given over 5-7 days Considered failure if no improvement Symptomatic colitis recurs in ~40-50% of patients Transition to maintenance therapy Purine analogues or immunosalicylates Cyclosporine Used when steroids fail > 50% response rate < 25% recurrence rate with maintenance therapy Renal insufficiency, opportunistic infections, seizures

Surgical indications Perforation - peritonitis Often masked by immunosuppression Severe GI hemorrhage Toxic megacolon Septic physiology with colon dilatation Associated with impending perforation Refractory to conservative measures No clinical improvement with corticosteroids or cyclosporine

Pre-Op Obtain enterostomal therapist consult Prophylactic antibiotics Anaerobic and Gram (-) coverage Stress steroids IV hydrocortisone

Operative Strategies Ultimate goal: Proctocolectomy and ileoanal anastomosis Physiologic state of the patient determines plan Options: 1) Colectomy with Hartmann s pouch or mucous fistula. Delayed proctocolectomy and ileoanal anastomosis 2) Immediate proctocolectomy with ileoanal anastomosis Advantage of 1) Recovery from acute illness Wean from immunosuppressives Maximize nutrition

Operative technique Standard Colectomy Wide mesenteric resection unnecessary Hartmann pouch Length is critical proximal end at sacral promontory Preservation of terminal IMA branches Evaluate for disease at planned site of resection Long Hartmann pouch proximal bowel in subq Mucous fistula Requires longer segment of distal colon Increased incidence of bleeding Laparoscopic

Fulminant UC

October 30, 1953 General George C. Marshall was awarded the Noble Peace Prize. He helped formulate the Marshall Plan for the rebuilding of Western Europe post-wwii and the expulsion of communism. When a thing is done, it s done. Don t look back.

Crohn s disease

Medical management Medical therapy is first line of defense Exceptions: perforation, obstruction, cancer, dysplasia Re-operation rate ~ 34% at 10 years1 Category Example Probiotics Lactobacillus Antibiotics Metronidazole, Ciprofloxacin Anti-inflammatory Sulfasalazine, 5-ASA s Immunosuppressives Corticosteroids, Cyclosporine Antimetabolites, Methotrexate Biologics Infliximab Michelassi F. Ann Surg 1991

Surgical indications No response to medical therapy Intolerance of side effects Prednisone (cataracts, aseptic necrosis, weigh gain) Antimetabolites (pancreatitis, neutropenia, infection) Obstruction Symptomatic fistulas Associated with obstruction/abscess Disabling rectovaginal or enterocutaneous fistulas Ileosigmoid fistula Abscess Not amenable to CT drainage Malignancy relative risk increased x3

Operative treatment Esophageal, Gastric, Duodenal Uncommon locations for disease Surgical treatment limited to duodenum Degree of obstruction best assessed w/contrast study Endoscopic diagnosis: noncaseating granulomas Gastrojejunostomy with vagotomy preferred treatment

Operative treatment Small bowel (jejunum, ileum) Small bowel associated with highest recurrence Most commonly presents as obstruction Concern for short bowel syndrome Segmental resection Reserved for long areas of stricture Resected segment should be as short as possible Palpate mesenteric margin of bowel Inspect entire bowel!

Operative treatment Stricturoplasty Useful for short, isolated strictures causing obstruction Saves bowel length 2 major techniques: Heineke Mikulicz (5-7cm) Finney (10-15cm) Rare incidence of adenocarcinoma at stricture site Biopsy active ulcer on mesenteric side Contraindicated in the presence of abscess, phlegmon, or fistula

Stricturoplasty Heineke-Mikulicz Finney

Operative treatment Ileocolic Disease Most common location (~50% Crohn s pts) Resection, End-to-end anastomosis Colonoscopy for post-op surveillance The wider the better Often associated with intra-abdominal abscess/fistula Most common associated fistula is ileosigmoid Externalize anastomosis as loop ileostomy in the presence of abscess Disease recurrence increases with # resections Post-op recurrence Decreased with mesalamine Increased with tobacco use

Operative treatment Colonic Disease Present in 30-45% of Crohn s patients Often difficult to distinguish from UC Similar to UC endoscopically and macroscopically Increased frequency of pyoderma gangrenosum

Operative treatment Colonic disease Indications for surgical treatment Obstruction/stricture Malignancy Side effects or failure of medical therapy Growth retardation in children (bone age, IGF-1) Toxic megacolon Segmental vs. Pancolonic disease Recurrence risk

Operative treatment Operative Procedures Total proctocolectomy with end-ileostomy Traditional treatment for Crohn s colitis Ideal in patients with anal/rectal disease Intersphincteric approach 8-15% recurrence in proximal bowel Subtotal colectomy w/ileorectal or ileosigmoidostomy An option in absence of rectal/anal disease Avoids ostomy 70% recurrence rate Segmental resection Ideal for limited disease with obstructing stricture Some associated controversy

Operative treatment Anal Disease With Stenosis from stricture Poor response to medical therapy Ongoing fistulas and suppurative disease Usually extends proximally Ultimate need for fecal diversion Without stenosis Favorable response to medical therapy Protect sphincter is general rule Setons to prevent abscess Rectovaginal fistula

Postoperative Post-op chemoprophylaxis Reduces recurrence (~30-40%) Mesalamine 6-mercaptopurine Azathioprine Surveillance No clear guidelines With remaining colon scope every 2 years Risk reduction Tobacco use associated with 1/3 higher recurrence rate Appears to be dose-dependent

October 30, 1938 Orson Welles' "The War of the Worlds" aired on CBS radio. Many listeners believed that the radio dramatization was a live news event about a real Martian invasion

Questions Which of the following statements about inflammatory conditions of the colon is TRUE? A) The risk of malignancy with pancolonic UC is 1% to 2% per year B) UC is a mucosal disease that is associated with the development of strictures despite medical therapy C) Perianal lesions are relatively common in severe UC, but the rectum is usually spared D) NSAIDS are effective in the treatment of UC E) OCP s are associated with the development of inflammation of the colon that mimics UC histologically.

Questions A 45 y/o female with active Crohn s proctitis has a symptomatic anterior transphincteric ano-vaginal fistula. The most appropriate management is: A) a draining seton B) saucerization C) fibrin glue D) a cutting seton E) an endorectal advancement flap

Questions A 28 y/o female arrives in the ED with a 72hr h/o diffuse abdominal pain, n/v. She can tolerate only minimal oral intake without emesis. A CT is obtained:

Questions A 28 y/o female arrives in the ED with a 72hr h/o diffuse abdominal pain, n/v. She can tolerate only minimal oral intake without emesis. A CT is obtained. All of the following would be indicated except: A) insertion of NG tube B) endoscopy C) corticosteroids D) enteral nutrition E) exploratory laparotomy

Xray

Questions A 52 y/o female with Crohn s and 4-month h/o RLQ discomfort is seeking a 2nd opinion. 3 weeks ago she had an extensive work-up elsewhere. Colonoscopy and small-bowel follow through were normal. This xray was obtined 24hr ago. Best management would now be: A) elective laparotomy if her condition doesn t improve B) urgent ex-lap C) capsule endoscopy D) CT of abd/pel E) diagnostic laparoscopy

Questions Use of a seton should be considered in the management of anorectal fistulas associated with any of the following characteristics except: A) those tracking > 30% to 50% of the external sphincter B) anterior fistulas in women C) recurrent fistulas D) those associated with crohn s disease E) intersphincteric fistulas

questions 45 y/o male with crohn s has an asymptomatic intersphincteric fistula-in-ano. The most appropriate management would be: A) observation B) fibrin glue injection C) cutting seton D) fistulotomy E) botulinum toxin

questions 56 y/o female with h/o UC develops a painful area inferior to her ileostomy, as shown.

questions 56 y/o female with h/o UC develops a painful area inferior to her ileostomy, as shown. The most appropriate management would be: A) cholestyramine powder and reduction of the size of the ileostomy appliance opening B) antifungal powder C) high-dose systemic corticosteroids D) debridement followed by wound vac closures E) wide local excision with stoma relocation.