DIFFICULTDIFFICULTSMALL BOWEL SMALL BOWEL

CROHN’S DISEASECROHN’S DISEASE

John NorthoverJohn Northover

St Mark’s Hospital, LondonSt Mark’s Hospital, London

LOOK BEFORE YOU LEAP

LOOK BEFORE YOU LEAP

LOOK BEFORE YOU LEAP

LOOK BEFORE YOU LEAP

Causes of intestinal failureCauses of intestinal failureSt Mark’s & Hope, 1999-2002St Mark’s & Hope, 1999-2002

0

10

20

30

40

50

60

70%

pat

ient

s

Hope

St Mark's

Difficult SB Crohn’sDifficult SB Crohn’s

• Duodenal diseaseDuodenal disease

• Multiple stricturesMultiple strictures

• Enterocutaneous fistulaEnterocutaneous fistula

DuodenalDuodenalCrohn’sCrohn’s

A few factsA few facts

• Rare - <5%Rare - <5%

• Differential diagnosis Differential diagnosis

• Rarely sole siteRarely sole site

• Often overshadowedOften overshadowed

Duodenum plus . . . .Duodenum plus . . . .

• D3 strictureD3 stricture

• Advanced ileal Advanced ileal diseasedisease

Clinical scenariosClinical scenarios

• ‘‘Peptic ulcer-like’Peptic ulcer-like’

• ObstructionObstruction

• FistulaFistula

Patterns of diseasePatterns of disease

**

SymptomsSymptoms

• ‘‘Peptic ulcer’ pain Peptic ulcer’ pain 70%70%

• Vomiting Vomiting 50%50%

• Weight loss Weight loss 26%26%

• Diarrhoea Diarrhoea 22%22%

• Bleeding Bleeding 7%7%

InvestigationInvestigation

• Barium studies Barium studies

• ScanningScanning

• EndoscopyEndoscopy

Conventional Ba mealConventional Ba meal

• Anatomical clarityAnatomical clarity

• Endoscopy neededEndoscopy needed

BaM in D3 obstructionBaM in D3 obstruction

• Poor viewPoor view

• No distal informationNo distal information

CT in D4 obstructionCT in D4 obstruction

EndoscopyEndoscopy

• Differential diagnosisDifferential diagnosis• DilatationDilatation

Treating obstructionTreating obstruction

• Balloon dilatationBalloon dilatation

• BypassBypass

• StrictureplastyStrictureplasty

Balloon dilatationBalloon dilatation

• May avoid surgeryMay avoid surgery

• Few dataFew data

• Distal diseaseDistal disease

BypassBypass

• Check for distal diseaseCheck for distal disease• ? need for vagotomy? need for vagotomy

– ““4/6 without4/6 withoutre-operation”re-operation” (Cleveland, (Cleveland,

‘83)‘83)

– ““Most re-do surgery after Vx; risk Most re-do surgery after Vx; risk of diarrhoea”of diarrhoea” (Lahey, ‘89)(Lahey, ‘89)

– ““Remains controversial”Remains controversial” (B’ham, ‘99)(B’ham, ‘99)

StrictureplastyStrictureplasty

• 13 patients (10 primary)13 patients (10 primary)

• 2/10 leaked2/10 leaked

• 6 re-strictured6 re-stricturedsurgerysurgery

• Overall 9/13 re-operatedOverall 9/13 re-operatedBirmingham, 1999Birmingham, 1999

‘‘Plasty v BypassPlasty v Bypass

• Historical and parallel comparisonHistorical and parallel comparison

• Bypass 21; strictureplasty 13Bypass 21; strictureplasty 13

• Same:Same:– Complications (2/21; 2/13)Complications (2/21; 2/13)

– RecurrenceRecurrenceRe-op. (1/21; 1/13)Re-op. (1/21; 1/13)

Cleveland Clinic, 1999Cleveland Clinic, 1999

Fistulating duodenal Crohn’sFistulating duodenal Crohn’s

• Usually secondaryUsually secondary

• To colon or terminal SBTo colon or terminal SB

• Duodenocutaneous Duodenocutaneous rarerare

• Most OK for oversewMost OK for oversew

D2-transverse colic fistulaD2-transverse colic fistula

• Normal duodenumNormal duodenum

• Penetrating ulcersPenetrating ulcers

• Simple closure Simple closure

after colectomyafter colectomy

Multiple Multiple stricturesstrictures

Multiple stricturesMultiple strictures

• Failure to thriveFailure to thrive

• ObstructionObstruction

Multiple stricturesMultiple strictures

Multiple stricturesMultiple strictures

• What trouble are they?What trouble are they?

• Other modalities?Other modalities?

• Previous surgery?Previous surgery?

• Is there a ‘dominant’ stricture?Is there a ‘dominant’ stricture?

• AND ONLY THEN . . . AND ONLY THEN . . .

Multiple stricturesMultiple strictures

• Might surgery help?Might surgery help?

• If so, what surgery?If so, what surgery?– (Bypass) (Bypass)

– ResectionResection

– StrictureplastyStrictureplasty

Multiple stricturesMultiple strictures

Pros and cons of strictureplastyPros and cons of strictureplasty

• Bowel conservationBowel conservation

• SafetySafety

• Relapse rateRelapse rate

Multiple stricturesMultiple strictures

Recurrence avoidanceRecurrence avoidanceOxford, 1995

Multiple stricturesMultiple strictures

Recurrence avoidanceRecurrence avoidance

2006 meta analysis2006 meta analysisTekkis et al.

StrictureplastyStrictureplastyWhat’s available?What’s available?

StrictureplastyStrictureplastyWhat’s available?What’s available?

StrictureplastyStrictureplastyWhat’s available?What’s available?

What do th

ey achieve?

What do th

ey achieve?

StrictureplastyStrictureplastyWhat’s available?What’s available?

StrictureplastyStrictureplastyBeware the occult strictureBeware the occult stricture

StrictureplastyStrictureplastyPick ‘n’ Mix . . .Pick ‘n’ Mix . . .

Enterocutaneous Enterocutaneous fistulafistula

Enterocutaneous fistulaEnterocutaneous fistula

Surgery rarely avoided

Surgery rarely avoided

Avoiding re-operationAvoiding re-operation

Avoiding re-operationAvoiding re-operation

NONOUNEXPECTED UNEXPECTED

EXTRA EXTRA PROCEDURESPROCEDURES

Avoiding DISASTERAvoiding DISASTER

DON’T GO IN

TOO EARLY

DON’T GO IN

TOO EARLY

Avoiding DISASTERAvoiding DISASTER

DON’T GO IN

TOO EARLY

DON’T GO IN

TOO EARLY

Avoiding DISASTERAvoiding DISASTER

DON’T GO IN

TOO EARLY

DON’T GO IN

TOO EARLY

WAIT!!WAIT!!

Avoiding DISASTERAvoiding DISASTER

DON’T GO IN

TOO EARLY

DON’T GO IN

TOO EARLY

WAIT!!WAIT!!and PREPAREand PREPARE

Exclude distal obstructionExclude distal obstruction

Exclude septic collectionsExclude septic collections

Find the optimalFind the optimal entry siteentry site

Pre-operative preparation Pre-operative preparation

Avoiding re-operationAvoiding re-operation

• ROADMAPROADMAP

• Composite imageComposite image

• Pre-operate in headPre-operate in head

DIFFICULTDIFFICULTSMALL BOWEL SMALL BOWEL

CROHN’S DISEASECROHN’S DISEASE

John NorthoverJohn Northover

St Mark’s Hospital, LondonSt Mark’s Hospital, London