Inflammatory bowel disease

The doctor said he will only concentrate on few things important to the surgical issues and leave
the details to the medical rotation

Inflammatory bowel disease (IBD): is an inflammatory disease characterized by intermittent

relapses. So once a person is labeled to have IBD he is labeled, therefore, there is no definitive cure
but it is manageable.

The Inflammatory bowel diseases primarily are; Ulcerative colitis, and Crohn's disease,

Ulcerative colitis
The major symptom is bloody diarrhea. It is characterized by:

1. Having diffuse inflammation of the colonic mucosa and it always affects the rectum and
extends proximally to the colon. So always, there is proctitis "inflammation of the rectum"
but can be proctitis with sigmoiditis or both with inflammation of any other parts of the
colon and severest form is pancolitis [where the whole colon is inflamed]
2. The colon is affected in continuity so there is no skip lesions or free areas in between the
affected areas.
3. It always stops at the cecum so it is a colonic disease [doesn’t affect the small bowel]
4. Pathologically, it is characterized by the presence of crypt abscesses there are colonoscopic
findings of patient with ulcerative colitis, you can see redness ulcers hemorrhage and
fissures. Like any other inflammation the findings depend on the degree of the severity [can
be mild, moderate or severe]
Crohn’s disease
The major presenting symptoms are abdominal pain, diarrhoea and weight loss. the diarrhea is
usually watery, doesn't contain significant amounts of blood or mucus.

It is characterized by

1. It affects the whole GIT {from mouth to anus} the commonest site is the ileocecal region in
close to 50% of the cases. Small intestine alone in 30%. The colon in 25% and of course you
can have combination of these area
2. There are skip lesions; what is the importance of the skip lesions? You may see a normal
area and you think it is the end of the disease but some other areas are affected e.g... Part
of the colon and part of the small bowel is affected and between them is normal
3. UC only affects the mucosa but Crohn’s disease is trans-mural disease affecting all the
layers of the GIT and this [inflammation of the all layers] will lead to strictures. If two
inflamed surfaces are in touch or an inflamed surface is in touch with adjacent organ it can
cause fistula. Therefore, fistula can be between bowel loops or bowel and adjacent organs
so you can have recto-vaginal fistula colono-vesical fistula entero-cutaneous fistula or
entero-colic fistula
4. Pathologically, it is characterized by the presence of granulomas but it is not present in all
cases, so its absence does not rule out the disease. You can't differentiate between UC and
Crohn based on the colonoscopy [some times even the expert can't], but you can see here
ulcers fissures and pseudopolyp formation which are swellings of the mucosa you can see
pseudo polyps ulceration of the rest of the mucosa and increased thickness of the wall so
the patient might have obstructive symptoms.
Here there is stricture at the descending colon caused by crohn’s
disease but it is difficult to differentiate it from tumor so stricture in the
colon can be tumor, Crohn or diverticulitis so biopsy is important

The difference between crohn's and UC

Intermediate colitis
It is a possible third entity of IBD. The term is used for the cases which doesn’t fulfill the criteria of
either UC or Crohn disease, so even with pathology we can't definitely say if it is Crohn or UC but
this concerns only the diseases of colon if there is small bowel involvement then it is definitely
Crohn.
Epidemiology
UC is commoner than Crohn disease a little bit.

The incidene is increasing since the 2nd world war and it can affect any age, with the peak
incidence being in young age. This makes the surgery more difficult because you are operating on
people in their productive period.

The disease affects nearly equally to both sex. There is geographical difference, it affects the
westerns more.

Extra-intestinal manifestations

IBD can affect the skin, skeletal system, eyes, the billiary system, amylodoisis, thrombo-embolic
phenomenon or renal stones. You have to understand that it is a multi-system disease and the
systemic manifestations will affect your line of management.

Here is Pyoderma gangrenosum

Treatment
Primarily it is medical there is a list of treatment. You can choose what suits your patient based on
the severity of the disease its location and the response of the treatment.

 It can be sulfasalazine with the new generation like mesalazine [not sure the spelling].

Mesalazine (INN, BAN), also known as mesalamine (USAN) or 5-aminosalicylic acid

(5-ASA), is an anti-inflammatory drug used to treat inflammatory bowel disease,
such as ulcerative colitis and mild-to-moderate Crohn's disease. Mesalazine is a
bowel-specific aminosalicylate drug that acts locally in the gut and has its
predominant actions there, thereby having few systemic side effects. Wiki

 Alternatively, you can give steroids by any means topical oral or IV,
  Immunosuppressive therapy like Azathioprin, 6 MP or Infliximab (monoclonal antibody
against TNF-alpha) sometimes metronidazole is added but you will choose the proper
combination
 Surgery only comes when the disease fails to respond to the medical treatment

Surgical indication for UC

Surgery is indicated in 5 scenarios

A. perforation

B. massive bleeding

C. toxic mega colon

D. failure of the medical management

E. cancer risk

There is no confusion in the first three and the patient will come in acute presentation like acute
appendicitis and perforated DU. On the other hand, failure of treatment is a bit ambiguous and
needs discussion between gastro-enterologist the surgeon the patient and the family and it is
difficult to decide because some cases respond to the treatment but relapse, some only respond to
steroids or immunosuppressive therapy so can we use them for long term?!! When do we stop ?

The cancer risk: in pancolitis there is a risk of CRCA in 10 years but the yearly risk is 1% and since
the peak incidence is in young age, the patient will have significant risk in his 40s or 50s so this also
needs discussion [doctor: personally I will wait the patient to finish his education get married and
have kids with colonoscopic surveillance]

Student: what is toxic mega colon?

The colon gets dilated and patient become toxic and if left untreated it will Perforate

The surgery
We know that UC affects the rectum and colon so the treatment is to remove them in total procto-
colectomy it is a major surgery but curative and there is no such thing as partial colectomy. Some
doctors leave the rectum to save the anal canal and retain continence, but this is wrong because as
you know rectum is always affected so the good choice is total colectomy.

What about the continence??

In the past patients would end up with permanent ileostomy but now we create from the small
intestine a new rectum and join it to the anal canal we call it Total procto- colectomy, ileal pouch &
pouch-anal anastomosis. The success is more than 80% with reasonable life style.
We may use temporary ileostomy if the heeling is poor like patient who uses steroids.

If successful the patient will have normal filling sensation, defer defecation discriminate between
stool and gas and have up to 6 bowel movements /day which is better than permanent ileostomy.

You are working in the pelvic area so sexual dysfunction is possibility that is why timing is very
important.

The pouch can get inflamed (pouchitis) but treated medically

Surgery for Crohn’s disease

It follows different philosophy because the disease affects the whole GIT and relapses a lot so you
cannot cure it.

Accordingly, the approach is conservative, you only operate when there is a complication, and you
will limit your surgery to the area of complication.

There are complications in which the indication for surgery is absolute like free perforation and
massive bleeding but fortunately, they are very rare.

Why free perforation is very rare ?

Because omentum will cover and stuck the inflamed areas of the bowel.

There is nothing you can do as a prophylaxis to cancer

Relative & optional indications

Crohn’s disease is common to have strictures, which in early phases respond to medical treatment
later will lead to chronic obstruction (when to intervene?).

Malabsorbtion is another possible complication

Abscesses: drained might followed by surgery or not. Toxic mega colon (very rare) and fistula
Therefore, you will study the complication and if you decide to intervene limit your surgery to the
complication

What is the outcome ?

In UC, you can cure the patient but in Crohn you cannot cure. The cumulative death risk is
increased by two folds, which means that any patient with Crohn’s disease has double chance to
die compared to his equivalent 70% need one surgery in their lifetime.

Morbidity is significant

• 50% will have recurrence within 10 year

 • 25% will have another surgery.
• Cancer: was reported in all parts of GIT but the incidence is much less than that of UC

How do we treat intermediate colitis?

If you are not sure that it is UC, treat it conservatively and never do a pouch