rob padwick mrcs 27 th july 2011
DESCRIPTION
CHALLENGES IN SURGICAL MANAGEMENT OF INFLAMMATORY BOWEL DISEASE. Rob Padwick MRCS 27 th July 2011. Aims. Management of severe (fulminant) colitis Crohn’s disease. ULCERATIVE COLITIS (UC). Prevalence 0.15% Unknown Aetiology; Familial/Genetic Smoking REDUCES risk Immunological response - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: Rob Padwick MRCS 27 th July 2011](https://reader036.vdocument.in/reader036/viewer/2022062803/5681474c550346895db49014/html5/thumbnails/1.jpg)
Rob Padwick MRCS27th July 2011
CHALLENGES IN SURGICAL
MANAGEMENT OF INFLAMMATORY
BOWEL DISEASE
![Page 2: Rob Padwick MRCS 27 th July 2011](https://reader036.vdocument.in/reader036/viewer/2022062803/5681474c550346895db49014/html5/thumbnails/2.jpg)
Aims
Management of severe (fulminant) colitis
Crohn’s disease
![Page 3: Rob Padwick MRCS 27 th July 2011](https://reader036.vdocument.in/reader036/viewer/2022062803/5681474c550346895db49014/html5/thumbnails/3.jpg)
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)
![Page 4: Rob Padwick MRCS 27 th July 2011](https://reader036.vdocument.in/reader036/viewer/2022062803/5681474c550346895db49014/html5/thumbnails/4.jpg)
ACUTE COMPLICATIONS OF UC
1. Acute severe (fulminating) colitis
2. Toxic megacolon
3. Perforation / Abscess
4. Bleeding
![Page 5: Rob Padwick MRCS 27 th July 2011](https://reader036.vdocument.in/reader036/viewer/2022062803/5681474c550346895db49014/html5/thumbnails/5.jpg)
LONG-TERM COMPLICATIONS OF UC
1. Strictures
2. Recurrent Acute Attacks
3. Steroid Dependence
4. Colorectal Cancer
![Page 6: Rob Padwick MRCS 27 th July 2011](https://reader036.vdocument.in/reader036/viewer/2022062803/5681474c550346895db49014/html5/thumbnails/6.jpg)
ACUTE SEVERE ULCERATIVE COLITIS
History and examination
• Bloody diarrhoea with mucus
• Urgency, abdo cramps
• Tachycardia, dehydration, pyrexia, peritonism,
• PR blood / mucus
![Page 7: Rob Padwick MRCS 27 th July 2011](https://reader036.vdocument.in/reader036/viewer/2022062803/5681474c550346895db49014/html5/thumbnails/7.jpg)
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
![Page 8: Rob Padwick MRCS 27 th July 2011](https://reader036.vdocument.in/reader036/viewer/2022062803/5681474c550346895db49014/html5/thumbnails/8.jpg)
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.
![Page 9: Rob Padwick MRCS 27 th July 2011](https://reader036.vdocument.in/reader036/viewer/2022062803/5681474c550346895db49014/html5/thumbnails/9.jpg)
ACUTE SEVERE ULCERATIVE COLITIS
TREATMENT
2. Medical (cont.)
Steroids
Azathioprine
• Purine analogue immunosuppressant
• Steroid sparing
![Page 10: Rob Padwick MRCS 27 th July 2011](https://reader036.vdocument.in/reader036/viewer/2022062803/5681474c550346895db49014/html5/thumbnails/10.jpg)
ACUTE SEVERE ULCERATIVE COLITIS
TREATMENT
2. Medical (cont.)
Steroids
Azathioprine
5-ASA
• Little / no role in acute setting
![Page 11: Rob Padwick MRCS 27 th July 2011](https://reader036.vdocument.in/reader036/viewer/2022062803/5681474c550346895db49014/html5/thumbnails/11.jpg)
ACUTE SEVERE ULCERATIVE COLITIS
TREATMENT
2. Medical (cont.)Steroids
AzathioprineSalicylatesOther• PPI• Antibiotics• DVT prophylaxis
![Page 12: Rob Padwick MRCS 27 th July 2011](https://reader036.vdocument.in/reader036/viewer/2022062803/5681474c550346895db49014/html5/thumbnails/12.jpg)
ACUTE SEVERE ULCERATIVE COLITIS
TREATMENT
2. Medical (cont.)
Cyclosporin
• Immunosuppressant
• Steroid failures at 5 days
• Remission in 50%
• Reduces need for emergency surgery
![Page 13: Rob Padwick MRCS 27 th July 2011](https://reader036.vdocument.in/reader036/viewer/2022062803/5681474c550346895db49014/html5/thumbnails/13.jpg)
MEDICAL MANAGEMENT SUMMARY
The Oxford criteria the five day rule Truelove & Jewell 1974
Azathioprine maintenance of remission
Cyclosporin induction of remission McCormack G
2002
![Page 14: Rob Padwick MRCS 27 th July 2011](https://reader036.vdocument.in/reader036/viewer/2022062803/5681474c550346895db49014/html5/thumbnails/14.jpg)
MEDICAL MANAGEMENT CHALLENGES
Uncertain end points
Masked sepsis
Late relapse
![Page 15: Rob Padwick MRCS 27 th July 2011](https://reader036.vdocument.in/reader036/viewer/2022062803/5681474c550346895db49014/html5/thumbnails/15.jpg)
ACUTE FULMINATING COLITIS (UC)
TREATMENT
3. Surgical management
• Failure of medical at 5 days (25-50%)
• Toxic megacolon
• Perforation
• Bleeding
![Page 16: Rob Padwick MRCS 27 th July 2011](https://reader036.vdocument.in/reader036/viewer/2022062803/5681474c550346895db49014/html5/thumbnails/16.jpg)
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
![Page 17: Rob Padwick MRCS 27 th July 2011](https://reader036.vdocument.in/reader036/viewer/2022062803/5681474c550346895db49014/html5/thumbnails/17.jpg)
Postoperative management
• Wean steroids
• Monitor stump (e.g.proctitis)
• Monitor/treat sepsis
• Counseling via Multi-Disciplinary Team
![Page 18: Rob Padwick MRCS 27 th July 2011](https://reader036.vdocument.in/reader036/viewer/2022062803/5681474c550346895db49014/html5/thumbnails/18.jpg)
TOXIC MEGACOLON
• ~45% mortality
• Surgery
• Non-resolution
• Impending or active perforation
![Page 19: Rob Padwick MRCS 27 th July 2011](https://reader036.vdocument.in/reader036/viewer/2022062803/5681474c550346895db49014/html5/thumbnails/19.jpg)
PERFORATION
• More common in UC than Crohn’s
• Greatest risk is with first episode
• Especially splenic flexure, sigmoid colon
• Beware lack of signs!
![Page 20: Rob Padwick MRCS 27 th July 2011](https://reader036.vdocument.in/reader036/viewer/2022062803/5681474c550346895db49014/html5/thumbnails/20.jpg)
HAEMORRHAGE
• Massive bleeding unusual
• 0-10%
• Colectomy is surgical procedure of choice
![Page 21: Rob Padwick MRCS 27 th July 2011](https://reader036.vdocument.in/reader036/viewer/2022062803/5681474c550346895db49014/html5/thumbnails/21.jpg)
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
![Page 22: Rob Padwick MRCS 27 th July 2011](https://reader036.vdocument.in/reader036/viewer/2022062803/5681474c550346895db49014/html5/thumbnails/22.jpg)
Crohn’s disease
![Page 23: Rob Padwick MRCS 27 th July 2011](https://reader036.vdocument.in/reader036/viewer/2022062803/5681474c550346895db49014/html5/thumbnails/23.jpg)
![Page 24: Rob Padwick MRCS 27 th July 2011](https://reader036.vdocument.in/reader036/viewer/2022062803/5681474c550346895db49014/html5/thumbnails/24.jpg)
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
![Page 25: Rob Padwick MRCS 27 th July 2011](https://reader036.vdocument.in/reader036/viewer/2022062803/5681474c550346895db49014/html5/thumbnails/25.jpg)
Aetiology
•Largely unknown
•2-4x as common in smokers
•Genes – Chromosomes 3, 7, 12, HLA B27
•Family history
•Infective agents – Measles, Mumps, TB
![Page 26: Rob Padwick MRCS 27 th July 2011](https://reader036.vdocument.in/reader036/viewer/2022062803/5681474c550346895db49014/html5/thumbnails/26.jpg)
Pathological features
•Transmural inflammation
•Fissures
•Non-caseating granulomas
•Skip lesions
![Page 27: Rob Padwick MRCS 27 th July 2011](https://reader036.vdocument.in/reader036/viewer/2022062803/5681474c550346895db49014/html5/thumbnails/27.jpg)
Clinical features
•Diarrhoea
•Crampy Abdominal pain
•Weight loss
•Fever
•Perianal sepsis
•PR Bleeding
![Page 28: Rob Padwick MRCS 27 th July 2011](https://reader036.vdocument.in/reader036/viewer/2022062803/5681474c550346895db49014/html5/thumbnails/28.jpg)
ACUTE COMPLICATIONS ININTESTINAL CROHN’S DISEASE
Investigation
• Haematology, biochemistry
• AXR, CxR
• Stool Culture
• Contrast study / CT
• MRI enteroclysis
![Page 29: Rob Padwick MRCS 27 th July 2011](https://reader036.vdocument.in/reader036/viewer/2022062803/5681474c550346895db49014/html5/thumbnails/29.jpg)
1. Aims
• Palliate symptoms
• Control infection
• Correct nutrition
There is NO CURE !
TREATMENT
![Page 30: Rob Padwick MRCS 27 th July 2011](https://reader036.vdocument.in/reader036/viewer/2022062803/5681474c550346895db49014/html5/thumbnails/30.jpg)
1. Medical
• Salicylates
• Azathioprine
• Steroids
• Biological agents (e.g. infliximab)
2 Surgical
TREATMENT
![Page 31: Rob Padwick MRCS 27 th July 2011](https://reader036.vdocument.in/reader036/viewer/2022062803/5681474c550346895db49014/html5/thumbnails/31.jpg)
• Required in 75% of cases
• Indications;
• Failed medical treatment
• Stricture / Obstruction
• Abscess
• Fistulae
• Bleeding
SURGERY IN INTESTINALCROHN’S DISEASE
![Page 32: Rob Padwick MRCS 27 th July 2011](https://reader036.vdocument.in/reader036/viewer/2022062803/5681474c550346895db49014/html5/thumbnails/32.jpg)
1. Stricturoplasty
• Avoids resection
• All strictures < 2cm
2. Limited bowel resection
SURGERY IN INTESTINALCROHN’S DISEASE
![Page 33: Rob Padwick MRCS 27 th July 2011](https://reader036.vdocument.in/reader036/viewer/2022062803/5681474c550346895db49014/html5/thumbnails/33.jpg)
PERIANAL DISEASE
GENERAL
• > 50%
• Fissures
• Abscess
• Fistulae
• May be multiple and complex
![Page 34: Rob Padwick MRCS 27 th July 2011](https://reader036.vdocument.in/reader036/viewer/2022062803/5681474c550346895db49014/html5/thumbnails/34.jpg)
PERIANAL DISEASE
FISTULAE
• Control sepsis
• Define and eradicate tracts
• Preserve sphincter function
Vagina Anus
![Page 35: Rob Padwick MRCS 27 th July 2011](https://reader036.vdocument.in/reader036/viewer/2022062803/5681474c550346895db49014/html5/thumbnails/35.jpg)
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
![Page 36: Rob Padwick MRCS 27 th July 2011](https://reader036.vdocument.in/reader036/viewer/2022062803/5681474c550346895db49014/html5/thumbnails/36.jpg)
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
![Page 37: Rob Padwick MRCS 27 th July 2011](https://reader036.vdocument.in/reader036/viewer/2022062803/5681474c550346895db49014/html5/thumbnails/37.jpg)
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
![Page 38: Rob Padwick MRCS 27 th July 2011](https://reader036.vdocument.in/reader036/viewer/2022062803/5681474c550346895db49014/html5/thumbnails/38.jpg)
Air under the diaphragm
![Page 39: Rob Padwick MRCS 27 th July 2011](https://reader036.vdocument.in/reader036/viewer/2022062803/5681474c550346895db49014/html5/thumbnails/39.jpg)
Wrigler’s Sign