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General Principles of Medical and Surgical
Management of Inflammatory Bowel Disease
Jeraldine S. Orlina
Colorectal Conference
December 22, 2005
Medical Therapy of Ulcerative Colitis
5-Aminosalicyclic acid agents Corticosteroids Cyclosporine 6-Mercaptopurine Azathioprine
5-Aminosalicylic Acid Agents
Sulfasalazine
- 5-ASA linked to sulfapyridine by an azo bond
- poorly absorbed in upper GI tract
- principle use to maintain remission
Operative Indications
Failure of medical therapy Obstruction Fistula or abscess Hemorrhage Growth retardation (in pediatric population) Perforation of carcinoma Extraintestinal manifestations
Preparation of the Patient
Endoscopic and Radiologic studies Correction of dehydration, electrolyte
deficiencies, coagulation deficits, and anemia
Optimization of comorbid conditions Nutritional optimization Pre-op marking for stoma (if needed) Bowel prep
Preparation of patient
Withdrawal of immunosuppressives Perioperative antibiotics Stress dose steroids DVT prophylaxis
Strategic Planning for Surgery
Midline incision to preserve potential stoma sites
Preservation of small bowel Resection margins—extended resection
margins are unnecessary Use of temporary stoma
Management of Small Bowel Crohn’s Diesease
Chronic obstruction (35%) Internal fistulas (30%) Intractability (22%) Abscess formation (11%)
Types of Operations
Small bowel resection Multiple small bowel resections (with
enteroenterorostomy, diversion, or both) Bypass Strictureplasty Balloon dilatation
Resection
Most common surgical procedure Wide resection unnecessary Division of inflamed mesentery
Indications for Strictureplasty
Diffuse involvement of small bowel with multiple strictures
Strictures in a pt who has undergone prev major resection of small bowel
Rapid recurrence of disease manifested as obstruction
Stricture in pt with short bowel syndrome Nonphlegmonous fibrotic stricture
Relative Contraindications for Stictureplasty
Free or contained perforation of the small bowel Phlegmonous inflammation, internal fistula, or
external fistula involving the affected site Multiple strictures within a short segment Stricture in close proximity to a site chosen for
resection Colonic strictures Hypoalbuminemia
Heineke-Mikulicz Strictureplasty
Finney Strictureplasty
Side-to-side isoperistaltic strictureplasty
Stapled Strictureplasty
Complications
Hemorrhage form suture line Restricture at strictureplasty site Fistula/Abscess/Leak Small bowel adenocarcinoma
Take Home Points
Conservative Management Preservation of small bowel