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General Principles of Medical and Surgical Management of Inflammatory Bowel Disease. Jeraldine S. Orlina Colorectal Conference December 22, 2005. Medical Therapy of Ulcerative Colitis. 5-Aminosalicyclic acid agents Corticosteroids Cyclosporine 6-Mercaptopurine Azathioprine.

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general principles of medical and surgical management of inflammatory bowel disease

General Principles of Medical and Surgical Management of Inflammatory Bowel Disease

Jeraldine S. Orlina

Colorectal Conference

December 22, 2005

medical therapy of ulcerative colitis
Medical Therapy of Ulcerative Colitis
  • 5-Aminosalicyclic acid agents
  • Corticosteroids
  • Cyclosporine
  • 6-Mercaptopurine
  • Azathioprine
5 aminosalicylic acid agents
5-Aminosalicylic Acid Agents
  • Sulfasalazine

- 5-ASA linked to sulfapyridine by an azo bond

- poorly absorbed in upper GI tract

- principle use to maintain remission

operative indications
Operative Indications
  • Failure of medical therapy
  • Obstruction
  • Fistula or abscess
  • Hemorrhage
  • Growth retardation (in pediatric population)
  • Perforation of carcinoma
  • Extraintestinal manifestations
preparation of the patient
Preparation of the Patient
  • Endoscopic and Radiologic studies
  • Correction of dehydration, electrolyte deficiencies, coagulation deficits, and anemia
  • Optimization of comorbid conditions
  • Nutritional optimization
  • Pre-op marking for stoma (if needed)
  • Bowel prep
preparation of patient
Preparation of patient
  • Withdrawal of immunosuppressives
  • Perioperative antibiotics
  • Stress dose steroids
  • DVT prophylaxis
strategic planning for surgery
Strategic Planning for Surgery
  • Midline incision to preserve potential stoma sites
  • Preservation of small bowel
  • Resection margins—extended resection margins are unnecessary
  • Use of temporary stoma
management of small bowel crohn s diesease
Management of Small Bowel Crohn’s Diesease
  • Chronic obstruction (35%)
  • Internal fistulas (30%)
  • Intractability (22%)
  • Abscess formation (11%)
types of operations
Types of Operations
  • Small bowel resection
  • Multiple small bowel resections (with enteroenterorostomy, diversion, or both)
  • Bypass
  • Strictureplasty
  • Balloon dilatation
resection
Resection
  • Most common surgical procedure
  • Wide resection unnecessary
  • Division of inflamed mesentery
indications for strictureplasty
Indications for Strictureplasty
  • Diffuse involvement of small bowel with multiple strictures
  • Strictures in a pt who has undergone prev major resection of small bowel
  • Rapid recurrence of disease manifested as obstruction
  • Stricture in pt with short bowel syndrome
  • Nonphlegmonous fibrotic stricture
relative contraindications for stictureplasty
Relative Contraindications for Stictureplasty
  • Free or contained perforation of the small bowel
  • Phlegmonous inflammation, internal fistula, or external fistula involving the affected site
  • Multiple strictures within a short segment
  • Stricture in close proximity to a site chosen for resection
  • Colonic strictures
  • Hypoalbuminemia
complications
Complications
  • Hemorrhage form suture line
  • Restricture at strictureplasty site
  • Fistula/Abscess/Leak
  • Small bowel adenocarcinoma
take home points
Take Home Points
  • Conservative Management
  • Preservation of small bowel