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Rob Padwick MRCS 27 th July 2011

CHALLENGES IN SURGICAL MANAGEMENT OF INFLAMMATORY BOWEL DISEASE. Rob Padwick MRCS 27 th July 2011. Aims. Management of severe (fulminant) colitis Crohn’s disease. ULCERATIVE COLITIS (UC). Prevalence 0.15% Unknown Aetiology; Familial/Genetic Smoking REDUCES risk Immunological response

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Rob Padwick MRCS 27 th July 2011

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  1. CHALLENGES IN SURGICAL MANAGEMENT OF INFLAMMATORY BOWEL DISEASE Rob Padwick MRCS 27th July 2011

  2. Aims • Management of severe (fulminant) colitis • Crohn’s disease

  3. ULCERATIVE COLITIS (UC) • Prevalence 0.15% • Unknown Aetiology; • Familial/Genetic • Smoking REDUCES risk • Immunological response • Affects Large Bowel mucosa ONLY • Extra GI manifestations – eyes, joints, skin, liver and biliary tree

  4. ACUTE COMPLICATIONS OF UC Acute severe (fulminating) colitis Toxic megacolon Perforation / Abscess Bleeding

  5. LONG-TERM COMPLICATIONS OF UC • Strictures • Recurrent Acute Attacks • Steroid Dependence • Colorectal Cancer

  6. ACUTE SEVERE ULCERATIVE COLITIS History and examination • Bloody diarrhoea with mucus • Urgency, abdo cramps • Tachycardia, dehydration, pyrexia, peritonism, • PR blood / mucus

  7. ACUTE SEVERE ULCERATIVE COLITIS Investigations • U&E • FBC - WCC, Hb • LFT’s – Albumin • INR • CRP • ABG • AXR, Erect CxR, CT • Stool culture • Unprepared FOS with minimal insufflation - Confluent ulceration, erythema, contact bleeding

  8. ACUTE SEVERE ULCERATIVE COLITIS TREATMENT • Resuscitation – give blood, correct coagulopathy correct metabolic derangement 2. Medical Steroids • IV Hydrocortisone 100mg qds • 5 days if responding then oral steroids • Prednisolone 40mg o.d.

  9. ACUTE SEVERE ULCERATIVE COLITIS TREATMENT • Medical (cont.) Steroids Azathioprine • Purine analogue immunosuppressant • Steroid sparing

  10. ACUTE SEVERE ULCERATIVE COLITIS TREATMENT • Medical (cont.) Steroids Azathioprine 5-ASA • Little / no role in acute setting

  11. ACUTE SEVERE ULCERATIVE COLITIS TREATMENT • Medical (cont.) Steroids Azathioprine Salicylates Other • PPI • Antibiotics • DVT prophylaxis

  12. ACUTE SEVERE ULCERATIVE COLITIS TREATMENT • Medical (cont.) Cyclosporin • Immunosuppressant • Steroid failures at 5 days • Remission in 50% • Reduces need for emergency surgery

  13. MEDICAL MANAGEMENT SUMMARY • The Oxford criteria • the five day rule Truelove & Jewell 1974 • Azathioprine • maintenance of remission • Cyclosporin • induction of remission McCormack G 2002

  14. MEDICAL MANAGEMENT CHALLENGES • Uncertain end points • Masked sepsis • Late relapse

  15. ACUTE FULMINATING COLITIS (UC) TREATMENT • Surgical management • Failure of medical at 5 days (25-50%) • Toxic megacolon • Perforation • Bleeding

  16. OPERATION • Sub-total colectomy • Procedure of choice in the ill patient • Preserve rectal stump • Potential for Ileoanal pouch later (IPAA) • Alternative operations • Panproctocolectomy and end ileostomy

  17. Postoperative management • Wean steroids • Monitor stump (e.g.proctitis) • Monitor/treat sepsis • Counseling via Multi-Disciplinary Team

  18. TOXIC MEGACOLON • ~45% mortality • Surgery • Non-resolution • Impending or active perforation

  19. PERFORATION • More common in UC than Crohn’s • Greatest risk is with first episode • Especially splenic flexure, sigmoid colon • Beware lack of signs!

  20. HAEMORRHAGE • Massive bleeding unusual • 0-10% • Colectomy is surgical procedure of choice

  21. UC AND COLORECTAL CANCER • Risk increases with duration of disease; • 2% at 10 years • 8% at 20 years • 18% at 30 years (Eaden et al 2001) • Higher in severe colitis – 19x general population (Chambers et al 2005) • Colonoscopic Surveillance; • Colonoscopy at 10 years after diagnosis • Follow-up according to risk stratification (NICE 2011) • Dysplasia or malignancy on biopsy – proceed to total colectomy

  22. Crohn’s disease

  23. Crohn’s disease • Described in 1932 by Burrill Bernard Crohn • Prevalence 0.07% • Can affect the WHOLE GI TRACT • Ileocaecal region ~50% • 15-40 years old • Extra GI Manifestations – Eyes, Skin, Joints, Liver

  24. Aetiology • Largely unknown • 2-4x as common in smokers • Genes – Chromosomes 3, 7, 12, HLA B27 • Family history • Infective agents – Measles, Mumps, TB

  25. Pathological features • Transmural inflammation • Fissures • Non-caseatinggranulomas • Skip lesions

  26. Clinical features • Diarrhoea • Crampy Abdominal pain • Weight loss • Fever • Perianal sepsis • PR Bleeding

  27. ACUTE COMPLICATIONS ININTESTINAL CROHN’S DISEASE Investigation • Haematology, biochemistry • AXR, CxR • Stool Culture • Contrast study / CT • MRI enteroclysis

  28. TREATMENT • Aims • Palliate symptoms • Control infection • Correct nutrition There is NO CURE !

  29. TREATMENT • Medical • Salicylates • Azathioprine • Steroids • Biological agents (e.g. infliximab) 2 Surgical

  30. SURGERY IN INTESTINALCROHN’S DISEASE • Required in 75% of cases • Indications; • Failed medical treatment • Stricture / Obstruction • Abscess • Fistulae • Bleeding

  31. SURGERY IN INTESTINALCROHN’S DISEASE • Stricturoplasty • Avoids resection • All strictures < 2cm 2. Limited bowel resection

  32. PERIANAL DISEASE GENERAL • > 50% • Fissures • Abscess • Fistulae • May be multiple and complex

  33. PERIANAL DISEASE FISTULAE Anus Vagina • Control sepsis • Define and eradicate tracts • Preserve sphincter function

  34. CROHN’S AND COLORECTAL CANCER • 2-3x increased risk of colorectal cancer in Crohn’s Disease (Bernstein et al 2001) • Standard resection as opposed to total colectomy

  35. A 25 year old man presented with several months history of intermittent colicky abdominal pain. He noted some looseness of bowel movements during the past 6 months. He has lost about 1 stone in weight. Physical examination revealed a thin and young man. His temperature was normal. There was fullness in the RIF. Bowel sounds appeared to be hyperactive. PR examination was normal. Na: 129 Hb: 13.1 K: 2.9 WCC: 16 Urea: 15 Platelet: 600 Creatinine: 250 CRP: 200 a) State the likely diagnosis (1) Acute Terminal Ileal Crohn’s Disease

  36. b) Describe the obvious pathological feature of this disease shown in the picture above? (1 mark) Fat wrapping c) What are the radiological features of this disease? (2 marks) Any two of; Cobblestoning, pseudopolyps, skip lesions, stricturing, pseudodiverticulae d) What are the appropriate medical therapy for this disease (2 marks) Any two of; Salicylates, azathioprine, steroids, biologicals (e.g. infliximab) e) What are the indications for surgical intervention? (2 marks) Any two of; Failed Medical Therapy, Sricturing, Obstruction, Abscess, Fistulae, Bleeding e) What is Infliximab? (1 mark) Biological Agent - Anti-TNFa

  37. Air under the diaphragm

  38. Wrigler’s Sign

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