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 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

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 Biopsy 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
Hernia
Malignant
Closed loop
Volvulus

51. 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

52. 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

53. 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

54. Radiology for bowel obstruction
Extent of obstruction
Closed loop
Perforation
Hernia
Transition point
Determine need for operation

55. CT
Ventral hernia causing obstruction
Intussusception

56. Other imaging studies Small bowel follow through Enteroclysis
Capsule endoscopy
Gastrograffin enema

57. Gastrograffin enema

58. Initial management IVF resuscitation NGT decompression NPO Admission
Isotonic (LR or NS)
Electrolyte replacement
NGT decompression
NPO
Admission

59. 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

60. 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)

61. 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

62. Small Bowel Tumors Primary Mets Adenocarcinoma Carcinoid Lymphoma GIST
Melanoma
Others

63. 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

64. 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

65. 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

66. 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?

67. Abdominal CT

68. 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

69. 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

70. History, physical, labs and imaging will guide your differential …
RLQ pain
Anatomic
Infectious
Neoplastic
Obstruction
Inflammatory

71. 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.

72. Ulcerative Colitis

73. 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

74. 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

75. 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

76. Extraintestinal manifestations
40-60% of patients with primary sclerosing cholangitis have UC
Colectomy does not change course of PSC

77. Endoscopic findings Severe colitis causing hematochezia
Mucosal ulceration, erythema
and mucus

78. 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

79. 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

80. Medical treatment for Ulcerative Colitis
Acute flare
Systemic corticosteroids
Bowel rest
IVF hydration
Antibiotics (bacterial translocation/fulminate colitis)

81. Indications for surgical management of ulcerative colitis
Emergent
Fulminant colitis/toxic megacolon
Hemorrhage
Failure of medical management

82. 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

83. 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

84. 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

85. 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

86. Is it Crohn’s or Ulcerative Colitis?

87. Crohn’s vs UC on endoscopy