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Published byBrittney Shelton Modified over 8 years ago
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Crohn’s Disease and other Diseases of the Small Bowel
Anir Gupta, MD, FRCSC Assistant Professor Department of Surgery
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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?
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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
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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?
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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!
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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?
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Abdominal CT
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Crohn’s Disease Prevalence Genetic and environment
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
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Symptoms of Crohn’s Disease
Abdominal pain Diarrhea Weight loss Failure to thrive for children Complications Abscess – fevers Fistulas – draining wounds, diarrhea Obstruction
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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
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Crohn’s Disease
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Crohn’s Disease Areas of involvement Ileocecal – 70% Colon only – 20%
Small bowel only ~ 5% Perineal/anorectal ~ 10% Esophagus, stomach, duodenum ~ 1-5%
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Extraintestinal Manifestations
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Pathologic findings Endoscopy Biopsy Linear ulcers
Cobblestone (coalescence of ulcers) Skip lesions Biopsy Transmural involvement Apthous ulcers Noncaseating Granulomas
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Endoscopic findings in Crohn’s
Serpiginous ulcer Linear ulcer
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Endoscopic findings in Crohn’s
Cobblestoning
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Radiologic findings in Crohn’s
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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
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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
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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
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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
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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
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Surgery for Crohn’s “Creeping fat”
Inflammation of terminal ileum (right) and cecum (left) in ileocolectomy specimen
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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
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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?
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Abdominal series
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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?
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Abdominal CT
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Infarcted Small Bowel
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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?
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Abdominal CT
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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?
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CXR
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Omental Cake
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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?
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Abdominal CT
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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?
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Small bowel follow through
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Enteroclysis
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Capsule Endoscopy
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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?
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Abdominal CT
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Bowel obstruction
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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
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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)
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Bowel obstruction pathophysiology
gas and fluid accumulation proximal to obstruction increased intraluminal pressure bowel distension decreased motility increased bacterial load and change to anaerobes
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Classification of Bowel Obstruction
Partial Adhesions Complete Hernia Malignant Closed loop Volvulus
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Symptoms of obstruction
Colicky abdominal pain Nausea Vomiting Bilious vomiting Feculence suggests long standing or distal obstruction Obstipation Inability to tolerate some more solid foods
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Exam findings of obstruction
Abdominal distension May be minimal or absent in proximal obstructions Hypoactive or high-pitched bowel sounds Pain with exam usually requires urgent operation ALWAYS, ALWAYS, ALWAYS Check for hernias Rectal exam
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Laboratory findings in obstruction
Volume depletion Increased BUN/Creatinine Hypokalemia Leukocytosis Worrisome if more than mild elevation Acidosis (metabolic/lactic) Not a good indicator of ischemia because of venous mesenteric obstruction
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Radiology for bowel obstruction
Extent of obstruction Closed loop Perforation Hernia Transition point Determine need for operation
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CT Ventral hernia causing obstruction Intussusception
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Other imaging studies Small bowel follow through Enteroclysis
Capsule endoscopy Gastrograffin enema
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Gastrograffin enema
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Initial management IVF resuscitation NGT decompression NPO Admission
Isotonic (LR or NS) Electrolyte replacement NGT decompression NPO Admission
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Definitive management
Expectant / conservative (Non-operative) Adhesions – Partial obstruction Crohn’s Early post-operative Operative Complete/high-grade obstruction from adhesions Closed loop Ischemia Clear transition point on CT NOT due to adhesions Cancer, volvulus, hernia, stricture Failure to improve with non-operative treatment
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Surgery for obstruction
Laparoscopic or Open Lysis of adhesions Examine entire length of bowel Resection of ischemic segments 2nd look if viability is questioned Repair hernia/volvulus Adhesion prevention Hyaluronan-based agents (Seprafilm)
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Post-operative management
NGT decompression Await return of bowel function Consider nutritional support after 5-7 days Risk of recurrence 20-50% due to adhesions
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Small Bowel Tumors Primary Mets Adenocarcinoma Carcinoid Lymphoma GIST
Melanoma Others
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Small Bowel Tumors Adenocarcinoma
Most common in the duodenum and proximal jejunum ~ 50% of primary small bowel malignancies Treatment: wide surgical resection and lymphadenectomy No benefit to chemo/rad Mainly palliative
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Small Bowel Tumors Carcinoid
Arise from the enterochromaffin cells in the cysts of Lieberkuhn Secrete various active peptides 2nd most common site is the small bowel Usually asymptomatic May cause abdominal pain and weight loss Diagnosis 24 hr urine for 5-HIAA Chromogranin A Octreotide scan (Serotonin Receptor Scintigraphy) Treatment Wide surgical resection
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Small Bowel Tumors GIST Rare submucosal tumor Most common GI sarcoma
Previously referred to as leiomyoma or leimyosarcoma Peak incidence in 5th and 6th decades 90% positive for KIT (CD 117) Arise from pacemaker cells of the intestine, the Interstitial Cells of Cajal Treatment for primary, non metastatic disease: surgery Adjuvant therapy for unresectable tumors: Gleevec Survival predicated on tumor size and # of mitoses/50 HPF
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Case 11 77 yo F presents to your ED with a history of acute onset severe abdominal pain that “woke her up at 3 AM”. Past medical history is significant for CAD, MI and Afib. Past surgical history is significant for right fem-pop bypass for peripheral vascular disease. How would you approach this patient?
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Abdominal CT
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Mesenteric Ischemia Arterial Venous Thrombosis
Embolic Arrhythmias Post MI Structural heart disease Thrombotic Atherosclerosis Age Venous Thrombosis Hypercoagulable states Inflammation Malignancy Cirrhosis NOMI (Non Occlusive Mesenteric Ischemia) Low flow states
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Numerous Pathologic Processes affect the Same Organ…
Infectious CMV/Yersinia/Campylobacter Inflammatory CD/Radiation enteritis Neoplastic Benign adenomas Malignant Primary Adenocarcinoma Carcinoid Lymphoma Mets Melanoma Anatomic Adhesions Hernias Ischemic Embolic Thrombotic Venous Thrombosis NOMI
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History, physical, labs and imaging will guide your differential …
RLQ pain Anatomic Infectious Neoplastic Obstruction Inflammatory
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Final Points Bowel obstruction without history of abdominal surgery usually means they need surgery Conservative management for bowel obstruction requires close follow-up and decision making Crohn’s disease is a chronic disease with acute flares. Transmural means abscesses and fistulas.
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Ulcerative Colitis
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Ulcerative Colitis Prevalence Unlike crohn’s is curable with colectomy
15 per 100,000 people in U.S. Slightly more common than crohn’s Bimodal distribution 30’s and 70’s Unlike crohn’s is curable with colectomy
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Symptoms Vary based on degree of mucosal inflammation
Bloody diarrhea Cramping abdominal pain Tenesmus Acute flares and remission Toxic megacolon Feared complication of UC Fever, leukocytosis Requires urgent colectomy If patient has fistula, abscess, obstruction, perianal disease it is crohn’s not ulcerative colitis Symptoms relate to part of intestine involved intraluminal = UC intra and extraluminal=crohn’s
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Pathophysiology Only effects the colon Mucosal and submucosal only
Terminal “backwash” ileitis often confused with crohn’s Continuous involvement of rectum and colon Mucosal and submucosal only No fistula or abscesses b/c not transmural Crypt abscesses Psuedopolyps NO perianal disease
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Extraintestinal manifestations
40-60% of patients with primary sclerosing cholangitis have UC Colectomy does not change course of PSC
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Endoscopic findings Severe colitis causing hematochezia
Mucosal ulceration, erythema and mucus
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Radiology findings CT showing diffuse, mild inflammation
of the sigmoid colon due to UC “Lead pipe” appearance on contrast enema due to loss of haustra
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Medical treatment for Ulcerative Colitis
Maintenance of Remission Salicylates Corticosteroids Topical Systemic Immunosuppressants Azathioprine 6-MP Cyclosporine Methotrexate Infliximab (Remicade) Monitor for dysplasia/carcinoma Endoscopy Annually after 8 years Random biopsies throughout colon
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Medical treatment for Ulcerative Colitis
Acute flare Systemic corticosteroids Bowel rest IVF hydration Antibiotics (bacterial translocation/fulminate colitis)
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Indications for surgical management of ulcerative colitis
Emergent Fulminant colitis/toxic megacolon Hemorrhage Failure of medical management
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Indications for surgical management of ulcerative colitis
Elective Inability to tolerate medical therapy Intractable disease despite maximal medical therapy Development of dysplasia/carcinoma Risk of malignancy increases with time 2% after 10 years 8% after 20 years 18% after 30 years ANY dysplasia (mild or otherwise) is indication for total proctocolectomy
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Surgical treatment of ulcerative colitis
Emergent 3 stage Total abdominal colectomy (leaves rectum in place to be removed later) with end ileostomy Proctectomy (removal of remaining rectum) and j-pouch creation) with loop ileostomy Takedown of loop ileostomy
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Surgical treatment of ulcerative colitis
Elective 2 stage Proctocolectomy (removal of entire colon and rectum) with ileo-anal pouch anastomosis and protecting loop ileostomy Ileostomy takedown 3-6 months later
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Following surgery for ulcerative colitis
Tapering of steroids post-op Typically 6-8 bowel movements daily with j-pouch Most do not have night-time incontinence Anything less than total proctocolectomy needs surveillance for dysplasia Complications Pouchitis Anastomotic stricture Bowel obstructions from adhesions
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Is it Crohn’s or Ulcerative Colitis?
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Crohn’s vs UC on endoscopy
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