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Inflammatory bowel disease. Dr. Angus Lee SET 1 General Surgery. Burrill Crohn , an American Gastroenterologist, with his 2 other colleagues first described “Terminal ileitis” in 1932. Epidemiology of IBD. Incidence 2-15/100, 000 Prevalence 40-80/100,000

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inflammatory bowel disease

Inflammatory bowel disease

Dr. Angus Lee

SET 1 General Surgery

slide2

BurrillCrohn, an American Gastroenterologist, with his 2 other colleagues first described “Terminal ileitis” in 1932

epidemiology of ibd
Epidemiology of IBD
  • Incidence 2-15/100, 000
  • Prevalence 40-80/100,000
  • More common in developed countries; higher SES
  • More common in Jewish population; less common in Asian population
  • Presentation commonly at younger age ~ 20s;

but can occur at any age

  • First degree relative with Crohn’s : ~ 10% lifetime risk
  • Monozygotic twins: 58% for Crohn’s; 6% for UC
pathogenesis
Pathogenesis
  • Complex
  • Immunological
  • Genetic and environmental factors
  • eg. IBD1 gene encodes NODS2 which regulates intestinal epithelial cells immunity has been implicated
  • Role of smoking:

increases risk 2x in Crohn’s

but lower risk in UC

how to differentiate crohn s and uc
How to differentiate Crohn’s and UC?
  • Direct visualisation by endoscopy
  • Histological diagnosis
  • Radiological appearance
  • Antibodies: anti – Saccharomycescerevisiae (ASCA) for Crohns; antineutrophilcytoplasmic antibody (p- ANCA) for UC
distribution
Distribution

Crohn’s

UC

  • SB alone ~30-35%
  • Colon alone ~ 25-35%
  • Both ~ 30-50%
  • Perianal ~50%
  • Stomach and duodenum 5%
  • Rectum 50%
  • Proctosigmoid 30%
  • Extending beyond splenic flexure 20%
complications
Complications

UC

Crohn’s

  • Perforation
  • Haemorrhage
  • Toxic megacolon
  • Carcinoma
  • Perforation
  • Stricture
  • Fistula
  • Perianal complication
  • Malnutrition
  • Vit B12 deficiency
  • Stones: renal; gallbladder
medical management 5 asa
Medical management: 5- ASA
  • Depends on extent of disease and severity
  • 5-aminosalicylate (5- ASA)

eg. Sulfasalazine; mesalazine; olsalazine

  • Sulfasalazine: azo bond to sulfapyridine; bond broken down by colonic bacteria; therefore releasing active sulfasalazine
  • Side effects relate to sulphonamide component
  • Olsalazine: two 5 ASA
  • Mesalazine: enteric coating of 5 ASA; coating dissolves in TI
  • Distal disease --- 5 ASA enema/ suppository

(enema can only reach up to splenic flexure at most)

  • More extensive disease --- oral preparation
use of steroid
Use of steroid
  • Route:

PR suppository; enema; foam; oral; IV

  • Generally effective in inducing remission; not so effective in maintaining remission
  • Moderate cases: oral steroid
  • Severe cases: IV hydrocort
immunosuppressive drugs
Immunosuppressive drugs
  • Azathioprine
  • 6- mercaptopurine
  • Cyclosporin
  • Monoclonal antibody: targettingTNF alpha

eg. Infliximab

-useful for both ileal and colonic Crohn’s

- high response rate in severe cases and patients with

fistulae.

slide22

70% of Crohn’s require surgery

  • Surgery in UC can be potentially curative
indication
Indication

Crohn’s

UC

  • Failure of medical management
  • Obstruction
  • Fistulae
  • Abscess
  • Haemorrhage
  • Perforation
  • Growth retardation
  • Cancer
  • Failure of medical management
  • Toxic megacolon
  • Haemorrhage
  • Perforation
  • Cancer

- <1% from 10 years of onset

- 10-15% second decade

- >20% third decade

- ~ 1% increase of incidence after 10 years of colitis

surgical objectives for complications of crohn s disease
Surgical objectives for complications of Crohn’s disease

Preoperative Objectives

•   Maximize or exhaust nonsurgical treatment options prior to surgery

•   Surgical intervention should be limited to the treatment of symptomatic complications of Crohn’s disease

•   Evaluate nutritional status prior to surgery

•   Consider supplemental nutrition to improve nutritional parameters prior to surgery

Intraoperative Objectives

•   Spare bowel length

•   Utilize alternative strategies to resection when appropriate to preserve sufficient length of the remaining bowel; minimize short bowel syndrome

• Preserve ileocaecal valve if possible

•   Biopsy any suspicious ulcers or mucosa for malignancy

fistulae
Fistulae
  • Classification:

Spontaneous vs postoperative

Internal vs external

  • SNAP approach

Sepsis; Nutrition; Anatomy; Plan

choices of operation in uc
Choices of operation in UC

Emergency

Elective

  • Subtotal colectomy and ileostomy
  • Proctocolectomyand permanent ileostomy
  • Proctocolectomy and ileal pouch
  • Colectomy and ileal rectal anastomosis
  • Proctocolectomy and continent ileostomy
pouchitis
Pouchitis
  • Cumulative incidence: 15-53%
  • double risk if PSC
  • Treatment:

ciprofloxacin and metronidazole

  • VSL 3 probiotic was shown to be effective in maintaining remission in ~85% of pouchitis