Crohn’s Disease and other Diseases of the Small Bowel

1. Crohn’s Disease and other Diseases of the Small Bowel Anir Gupta, MD, FRCSC Assistant Professor Department of Surgery

2. Case 1 • A 45 yo M with a history of AIDS presents to your ED with nausea, vomiting, diarrhea and severe abdominal pain. How would you approach this patient?

3. CMV Enteritis • Most commonly affects the distal ileum and right colon • Colonoscopic findings include hemorrhagic, ulcerated lesions • Cytology: nuclear inclusions “owl’s eye” • Treatment: medical, not surgical • Gancyclovir/foscarnet

4. Case 2 • A 35 yo M who is otherwise healthy presents to your ED with fever, diarrhea and RLQ abdominal pain. How would you approach this patient?

5. Acute Ileitis • Etiology may be infectious or inflammatory (ie Crohn’s Disease) • Predominant etiology: infectious • Usual suspects: • Campylobacter • Yersinia • Salmonella • Shigella • Investigations – do a C&S, O&P ! • Mimics: appendicitis, crohn’s disease • Treatment: antibiotics, not surgery!

6. Case 3 • 57 yo man presents to your hospital with nausea, vomiting, and crampy abdominal pain. Past medical history significant for Crohn’s Disease. How would you approach this patient?

7. Abdominal CT

8. Crohn’s Disease • Prevalence • 4-10 per 100,000 • More prevalent in northern US and Ashkenazi pop. • Bimodal distribution (30’s and 60’s) • Genetic and environment • 1:5 have a family member with Crohn’s • NOD2 gene mutation = 40X risk of crohn’s • Chronic disease with acute flares • Different treatments for each phase • Goal is to delay surgery and improve QOL • No cure, only palliation

9. Symptoms of Crohn’s Disease • Abdominal pain • Diarrhea • Weight loss • Failure to thrive for children • Complications • Abscess – fevers • Fistulas – draining wounds, diarrhea • Obstruction

10. Crohn’s Disease • Often difficult to delineate between Crohn’s and Ulcerative Colitis • 15% have “indeterminate” colitis • Crohn’s • Sustained inflammation • Mouth to anus • Transmural • Types • Fistulizing • Fibrostenotic (stricturing) • Inflammatory

11. Crohn’s Disease

12. Crohn’s Disease • Areas of involvement • Ileocecal – 70% • Colon only – 20% • Small bowel only ~ 5% • Perineal/anorectal ~ 10% • Esophagus, stomach, duodenum ~ 1-5%

13. Extraintestinal Manifestations

14. Pathologic findings • Endoscopy • Linear ulcers • Cobblestone (coalescence of ulcers) • Skip lesions • Biopsy • Transmural involvement • Apthous ulcers • Noncaseating Granulomas

15. Endoscopic findings in Crohn’s Serpiginous ulcer Linear ulcer

16. Endoscopic findings in Crohn’s Cobblestoning

17. Radiologic findings in Crohn’s

18. Treatment of Crohn’s • Goals change based on presentation • Acute • Treat complications (abscess, fistula, obstruction) • Improve symptoms • Avoid surgery?? • Return to chronic phase • Chronic phase • Improve QOL • Maintain remission • Prevent flares

19. Medical Treatment for Crohn’s • Acute phase • Antibiotics for abscess/infection • Drain placement for large abscesses • Steroid pulse (systemic) • Immunomodulators • Infliximab (remicade) or adalimumab (humira) • NPO status • Nutritional support

20. Medical Treatment for Crohn’s • Chronic phase (Maintenance therapy) • Anti-inflammatory • 5-Aminosalicylic acid (5-ASA) • Mesalamine, mesalazine, sulfasalazine, Pentasa • Steroids • Topical and systemic • Antibiotics • Cipro for perineal disease • Flagyl following surgical resection • Immunomodulators • Azathioprine • 6-mercaptopurine (6-MP) • Cyclosporine • Methotrexate • Infliximab (remicade) • Monitor for development of neoplasia/dysplasia • Colonoscopy every 2-3years after first 10 years of diagnosis

22. Surgery for Crohn’s Disease • Indications • Complications • Abscess, perforation, fistula, obstruction, bleeding • Failure of medical management • Intolerance of medical therapy • Development of neoplasia • Most patients will eventually require surgery

23. Surgery for Crohn’s Disease • Removal of diseased intestine • Most common operation is ileocecectomy • Several segmental resections better than one long segment resection • Stricuroplasty for short or numerous strictures • Drainage of abscesses

24. Surgery for Crohn’s “Creeping fat” Inflammation of terminal ileum (right) and cecum (left) in ileocolectomy specimen

25. Surgical outcomes • Complication rates high • 15-30% • Wound infection • Anastomotic leaks • Good short-term resolution of symptoms • Duration of benefit dependent on severity of disease • Surgery begets more surgery for crohn’s patients

26. Case 4 • 57 yo F comes to your hospital with a 2 day history of nausea, vomiting, and abdominal pain. Her past surgical history is significant for a c-section in the past. She does not take any meds, no drug allergies, no other medical problems. She is mildly tachycardic, otherwise VSS. How would you approach this patient?

27. Abdominal series

28. Case 5 • 72 yo F comes into your ED with 3 day history of nausea, vomiting and obstipation. She is tachycardic, has a low grade fever, and her SBP is 90. Labs reveal a WBC of 13,000. How would you approach this patient?

29. Abdominal CT

30. Infarcted Small Bowel

31. Case 6 • You are asked to see an 69 yo F on the medical service. She has been obstipated for 2 days. She is tachycardic, her SBP is 90, her abdomen is distended and tympanitic. The ER doctor is concerned about a mass in her right groin that he feels is concerning for an abscess. How would you approach this patient?

33. Abdominal CT

35. Case 7 • A 54 yo M comes to your hospital with a 3 day history of nausea, vomiting and severe abdominal pain. He states that he has been suffering from chronic abdominal pain for several months now. He has lost 20 lbs in the past few months. He is tachycardic, with a distended, diffusely tender abdomen. How would you approach this patient?

36. CXR

37. Omental Cake

38. Case 8 • A 65 yo F with a previous history of melanoma presents to your hospital with nausea, vomiting and recurrent abdominal pain. She is anemic. How would you approach this patient?

39. Abdominal CT

40. Case 9 • You have been referred a patient with chronic intermittent abdominal pain. EGD is normal. Colonoscopy is normal. Patient is not obstipated, but does experience intermittent bloating and “constipation” along with his pain. How would you evaluate this patient?

41. Small bowel follow through

42. Enteroclysis

43. Capsule Endoscopy

44. Case 10 • A 65 yo F presents to your ED with nausea, vomiting and abdominal pain. She is obstipated. She has had surgery and adjuvant therapy in the past for ovarian cancer. How would you approach this patient?

45. Abdominal CT

46. Bowel obstruction

47. Bowel obstruction • Definition: a mechanical blockage of the intestine preventing passage of intestinal secretions and contents • Etiology: • Intraluminal • Intramural • Extrinsic • Most common reason for emergency general surgery admission • Approximately ½ million yearly • 300,000 per year will be operated on for SBO

48. Etiology of Bowel Obstruction • Previous operation – about 50% will need surgery • Adhesions – account for 75% of all obstructions • No previous operation – all need surgery/intervention • Hernia • Malignancy/tumor • Crohn’s disease • Malrotation/volvulus • Intussusception • Diverticulitis • Stricture (ischemic, radiation, crohn’s)

49. Bowel obstruction pathophysiology • gas and fluid accumulation proximal to obstruction • increased intraluminal pressure • bowel distension • decreased motility • increased bacterial load and change to anaerobes

50. Classification of Bowel Obstruction • Partial • Adhesions • Complete • Adhesions • Hernia • Malignant • Closed loop • Adhesions • Volvulus