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Peri-anal disease and IBD in Adolescence. Bruce D George John Radcliffe Hospital Oxford. Control intestinal symptoms Optimise growth impaired at time of diagnosis in 88% Facilitate normal social development. Aims of Management of Crohn’s disease in adolescence. Emergency perforation

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peri anal disease and ibd in adolescence

Peri-anal disease and IBD in Adolescence

Bruce D George

John Radcliffe Hospital

Oxford

aims of management of crohn s disease in adolescence
Control intestinal symptoms

Optimise growth

impaired at time of diagnosis in 88%

Facilitate normal social development

Aims of Management of Crohn’s disease in adolescence
indications for surgery in crohn s disease
Emergency

perforation

bleeding

acute colitis

Elective

obstruction

fistula

chronic ill health/failure of medical therapy

Indications for Surgery in Crohn’s disease
principles of surgery in adolescence
Similar to adults:

operate as soon as there is an indication

play safe

minimal resection

But also:

earlier surgery to facilitate growth and to avoid steroids

Principles of surgery in adolescence
difficult problems
Aggressive disease

Early recurrence

Psychological

chronic ill health

body image

height, weight

sexual development

stoma

Difficult problems
indications for surgery in ulcerative colitis
Acute colitis

Failure of medical therapy

chronic disease

recurrent acute attacks

Dysplasia

Impaired growth

Indications for surgery in Ulcerative Colitis
factors to consider
Overall fitness steroids, co-morbidity

Colon certainty of diagnosis

Psychology acceptability of stoma

Sphincters manometry, U/S

Nerves and tubes pelvic dissection

Factors to consider
surgical options in ulcerative colitis
Proctocolectomy and end ileostomy

Proctocolectomy and ileal pouch reconstruction

Colectomy and ileostomy (rectal stump)

Colectomy and ileorectal anastomosis

Surgical options in ulcerative colitis
anal crohn s disease
Anal Crohn’s disease

20-80% of patients with Crohn’s get perianal disease

Rectal > colonic > ileocaecal > small bowel

Anal Crohn’s disease
clinical features
Primary

Fissures

Skin tags

Ulcers

Secondary

Abscess/fistula

Strictures

Vaginal fistula

(malignancy)

Clinical features
variable natural history
Benign

fissures, tags

Variable

fistulae, strictures

Aggressive

cavitating ulcers, sepsis

Variable natural history
assessment of anal crohn s disease
General

Large bowel

colonoscopy

Small bowel

small bowel enema

Anus

inspection

EUA

ultrasound, MRI

Assessment of Anal Crohn’s disease
aims of treatment of anal crohn s
Minimise symptoms

Prevent complication

sepsis

incontinence

unhealed wounds

stenosis

Aims of Treatment of Anal Crohn’s
treatment options
Do nothing

Diet

elemental, TPN

Medical

antibiotics, immunosuppressants, anti-TNF alpha

Surgery

drain sepsis, local procedures, distant resection,

defunction, proctocolectomy

Treatment Options
treatment of specific lesions
Skin tags leave alone

Haemorrhoids surgery contraindicated

Fissures

if painless leave alone

if painful GTN, Botulinum

Treatment of Specific Lesions
slide23
Low Fistula

may heal spontaneously

if no rectal inflammation lay open

slide24
High fistula

unlikely to heal

ensure sepsis drained

anti-TNF alpha

?fibrin glue

defunction

proctocolectomy

slide25
Anal Ulcers

poor prognosis

maximal medical therapy

defunction

proctocolectomy

summary of anal crohn s disease
Thorough assessment

Tailoring treatment to individual

Symptom control

Prevention of complications

Accept defeat

Summary of Anal Crohn’s Disease