Download - Rob Padwick MRCS 27 th July 2011
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Rob Padwick MRCS27th July 2011
CHALLENGES IN SURGICAL
MANAGEMENT OF INFLAMMATORY
BOWEL DISEASE
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Aims
Management of severe (fulminant) colitis
Crohn’s disease
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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
ULCERATIVE COLITIS (UC)
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ACUTE COMPLICATIONS OF UC
1. Acute severe (fulminating) colitis
2. Toxic megacolon
3. Perforation / Abscess
4. Bleeding
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LONG-TERM COMPLICATIONS OF UC
1. Strictures
2. Recurrent Acute Attacks
3. Steroid Dependence
4. Colorectal Cancer
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ACUTE SEVERE ULCERATIVE COLITIS
History and examination
• Bloody diarrhoea with mucus
• Urgency, abdo cramps
• Tachycardia, dehydration, pyrexia, peritonism,
• PR blood / mucus
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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
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ACUTE SEVERE ULCERATIVE COLITIS
TREATMENT
1. 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.
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ACUTE SEVERE ULCERATIVE COLITIS
TREATMENT
2. Medical (cont.)
Steroids
Azathioprine
• Purine analogue immunosuppressant
• Steroid sparing
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ACUTE SEVERE ULCERATIVE COLITIS
TREATMENT
2. Medical (cont.)
Steroids
Azathioprine
5-ASA
• Little / no role in acute setting
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ACUTE SEVERE ULCERATIVE COLITIS
TREATMENT
2. Medical (cont.)Steroids
AzathioprineSalicylatesOther• PPI• Antibiotics• DVT prophylaxis
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ACUTE SEVERE ULCERATIVE COLITIS
TREATMENT
2. Medical (cont.)
Cyclosporin
• Immunosuppressant
• Steroid failures at 5 days
• Remission in 50%
• Reduces need for emergency surgery
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MEDICAL MANAGEMENT SUMMARY
The Oxford criteria the five day rule Truelove & Jewell 1974
Azathioprine maintenance of remission
Cyclosporin induction of remission McCormack G
2002
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MEDICAL MANAGEMENT CHALLENGES
Uncertain end points
Masked sepsis
Late relapse
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ACUTE FULMINATING COLITIS (UC)
TREATMENT
3. Surgical management
• Failure of medical at 5 days (25-50%)
• Toxic megacolon
• Perforation
• Bleeding
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OPERATION
1. Sub-total colectomy
• Procedure of choice in the ill patient
• Preserve rectal stump
• Potential for Ileoanal pouch later
(IPAA)
2. Alternative operations
• Panproctocolectomy and end ileostomy
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Postoperative management
• Wean steroids
• Monitor stump (e.g.proctitis)
• Monitor/treat sepsis
• Counseling via Multi-Disciplinary Team
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TOXIC MEGACOLON
• ~45% mortality
• Surgery
• Non-resolution
• Impending or active perforation
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PERFORATION
• More common in UC than Crohn’s
• Greatest risk is with first episode
• Especially splenic flexure, sigmoid colon
• Beware lack of signs!
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HAEMORRHAGE
• Massive bleeding unusual
• 0-10%
• Colectomy is surgical procedure of choice
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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
UC AND COLORECTAL CANCER
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Crohn’s disease
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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
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Aetiology
•Largely unknown
•2-4x as common in smokers
•Genes – Chromosomes 3, 7, 12, HLA B27
•Family history
•Infective agents – Measles, Mumps, TB
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Pathological features
•Transmural inflammation
•Fissures
•Non-caseating granulomas
•Skip lesions
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Clinical features
•Diarrhoea
•Crampy Abdominal pain
•Weight loss
•Fever
•Perianal sepsis
•PR Bleeding
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ACUTE COMPLICATIONS ININTESTINAL CROHN’S DISEASE
Investigation
• Haematology, biochemistry
• AXR, CxR
• Stool Culture
• Contrast study / CT
• MRI enteroclysis
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1. Aims
• Palliate symptoms
• Control infection
• Correct nutrition
There is NO CURE !
TREATMENT
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1. Medical
• Salicylates
• Azathioprine
• Steroids
• Biological agents (e.g. infliximab)
2 Surgical
TREATMENT
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• Required in 75% of cases
• Indications;
• Failed medical treatment
• Stricture / Obstruction
• Abscess
• Fistulae
• Bleeding
SURGERY IN INTESTINALCROHN’S DISEASE
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1. Stricturoplasty
• Avoids resection
• All strictures < 2cm
2. Limited bowel resection
SURGERY IN INTESTINALCROHN’S DISEASE
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PERIANAL DISEASE
GENERAL
• > 50%
• Fissures
• Abscess
• Fistulae
• May be multiple and complex
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PERIANAL DISEASE
FISTULAE
• Control sepsis
• Define and eradicate tracts
• Preserve sphincter function
Vagina Anus
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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
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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: 13.1K: 2.9 WCC: 16Urea: 15 Platelet: 600
Creatinine: 250 CRP: 200a) State the likely diagnosis (1)
Acute Terminal Ileal Crohn’s Disease
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b) Describe the obvious pathological feature of this disease shown in the picture above? (1 mark)Fat wrappingc) What are the radiological features of this disease? (2 marks)Any two of; Cobblestoning, pseudopolyps, skip lesions, stricturing, pseudodiverticulaed) 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, Bleedinge) What is Infliximab? (1 mark) Biological Agent - Anti-TNFa
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Air under the diaphragm
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Wrigler’s Sign