inflammatory%20bowel%20disease
INFLAMMATORY BOWEL DISEASE
Treatment Guideline Chart
Inflammatory bowel disease consists of ulcerative colitis and Crohn's disease.
Ulcerative colitis is a diffuse mucosal inflammation limited to the colon while Crohn's disease is a patchy, transmural inflammation that occurs in any part of the gastrointestinal tract.
The ileum and colon are the most frequently affected sites.

Inflammatory%20bowel%20disease Treatment

Surgical Intervention

Ulcerative Colitis 

  • Surgical resection is considered curative in cases of UC

Absolute Indications

  • Exsanguinating hemorrhage
  • Perforation or impending perforation
    • Persistent colonic dilatation, worsening peritonitis, presence of pneumatosis coli
  • Documented or strongly suspected carcinoma

Other Indications

  • Severe colitis with or without toxic megacolon (dilatation of the transverse colon >5.5 cm or cecum >9 cm) unresponsive to conventional maximal medical therapy
  • Less severe but medically intractable symptoms or intolerable medication side effects, or those who fail to show clinical improvement after 3-5 days of medical therapy
  • Patients with chronic UC who develop strictures
  • Growth failure in children despite maximal nutritional and medical therapy

Surgical Options

  • Laparoscopic surgery is the preferred approach in patients with medically refractory UC 
    • Associated with faster recovery, fewer adhesions and incisional hernias, lower intra- and postoperative morbidity, shorter hospital stay, improved female fecundity and better cosmesis
  • Temporary ileostomy
  • Segmental colectomy may be an option for patients with higher operative risk or poor functional status   
  • Subtotal colectomy with ileostomy followed by ileal pouch-anal anastomosis (IPAA) construction then finally followed with ileostomy closure is the preferred semi-elective procedure for patients with acute severe UC  
    • Safe and effective in patients with acute severe UC with massive colorectal hemorrhage or patients not responding to medical therapy  
  • Total abdominal colectomy with end ileostomy is recommended for patients with severe medically refractory UC, fulminant colitis, toxic megacolon or colonic perforation     
    • Modified-2-stage IPAA: Total abdominal colectomy with end ileostomy with rectum left in situ followed by restorative completion proctectomy and IPAA reconstruction with ileostomy take-down may be a surgical option in patients with medically refractory UC  
  • Proctocolectomy without ileostomy may be a surgical option for patients with refractory and corticosteroid-dependent UC   
  • Total proctocolectomy with permanent or end ileostomy   
    • Recommended for UC patients with visible dysplasia not amenable to endoscopic excision or colorectal carcinoma in order to remove all at-risk tissue  
    • Alternative procedure for patients with refractory and corticosteroid-dependent UC  
    • May be an option for patients with contraindications to IPAA
  • IPAA procedure: Gold standard for surgery after total proctocolectomy for medically refractory UC
  • Staged proctocolectomy wherein subtotal colectomy is done initially followed either by IPAA or permanent ileostomy is recommended in:
    • Surgical treatment of patients with acute severe colitis
    • Patients taking ≥20 mg Prednisolone daily for >6 weeks
    • Patients treated with anti-TNF
  • Ileo-rectal anastomosis (IRA) may be an option for patients with UC with minimally affected rectum   
    • Associated with better functional outcomes compared to IPAA but with higher risk for rectal dysplasia, cancer and dysplasia or cancer recurrence

Crohn's Disease 

  • Surgery is rarely curative for CD cases because condition may recur, but those who undergo it may have long-lasting remission
  • May be considered if the disease is limited to the distal ileum
  • May also be considered in children or adolescents whose disease has been diagnosed early, with the disease limited to the distal ileum, with potential growth impairment even with medications, and disease is refractory to conventional therapy

Indications

  • Failed medical management, worsening of symptoms or side effects of medication
  • With signs of impending perforations or actual perforations
  • Presence of intestinal strictures or obstructions, or tender abdominal mass
  • Presence of massive hemorrhage
  • Abscess not amenable to percutaneous drainage
  • Presence of perianal, rectovaginal, intestinal small bowel or sigmoid-gynecological fistulas
  • Presence of skin tags, hemorrhoids

Surgical Options    

  • The presence of acute suppuration is an indication for surgical drainage with or without placement of setons
    • Draining setons may be used for long-term disease control in patients with fistulizing anorectal CD
      • Help resolve inflammation and prevent anorectal sepsis by maintaining the external opening and allowing drainage
      • Combination therapy with biologic agents and seton drainage has been shown to improve fistula healing rates and is more cost-effective
  • Lay-open fistulotomy may be an option for selected CD patients with symptomatic, simple or uncomplicated low anal fistulas (<30% external anal sphincter involvement) without proctitis
  • Laparoscopic surgery is the recommended procedure for CD patients requiring surgery
    • Creation of a temporary stoma or diverting ileostomy should be considered in patients on steroids which cannot be withdrawn or significantly reduced before surgery or in patients with multiple risk factors (eg smoking, weight loss, steroid use)  
  • Laparoscopic resection of non-stricturing active disease of the terminal ileum (<40 cm) may be an alternative to Infliximab therapy
  • Laparoscopic resection of stricturing fibrotic disease is the preferred treatment option in patients with localized ileocecal CD
    • Resection is recommended for patients with symptomatic small bowel or anastomotic strictures which are not amenable to medical therapy and/or endoscopic dilatation   
  • Endoscopic dilatation may be an option for patients with short-segment (<5 cm), noninflammatory, symptomatic small bowel or anastomotic strictures without associated penetrating disease such as abscess or fistula   
  • Strictureplasty may be a safe option for the management of small bowel strictures and may be preferred over resection of long segments of bowel   
    • Preferred procedure for patients with multiple strictures separated by longer segments of grossly normal small bowel 
  • Defunctioning ileostomy to divert fecal stream may be performed on patients with non-acute refractory CD to allow for remission together with intensified medical therapy and avoid the need for colectomy
  • Total or subtotal colectomy with end ileostomy is the emergency procedure of choice for severe acute and refractory Crohn's colitis  
  • Segmental colectomy is indicated for CD patients with a single involved colonic segment   
  • Total colectomy with ileoproctostomy is indicated for CD patients with ≥2 involved colonic segments  
  • Total proctocolectomy with end ileostomy or proctectomy with colostomy creation is indicated for patients with CD involving the rectum 
  • Restorative proctocolectomy with IPAA may be an option for patients with refractory pancolonic CD without perianal or small bowel disease  
  • For patients with complex perianal fistulae, surgical options include advancement flaps, ligation of intersphincteric fistula tract (LIFT) or fibrin glue 
    • Endorectal advancement flaps and LIFT are surgical options for well-controlled CD patients with fistula-in-ano without sepsis
  • Fecal diversion with or without proctectomy may be an option for patients with severe anorectal fistulizing CD who are not adequately responsive to medical therapy, local surgical intervention or long-term seton drainage, to control anorectal sepsis and improve incontinence symptoms and overall quality of life
    • Permanent fecal diversion with proctectomy is recommended in patients with concomitant colonic disease, persistent proctitis or anorectal sepsis, previous temporal fecal diversion, >2 previous seton placements, fecal incontinence, and anal canal stenosis

Postoperative Recurrence 

  • Predictors of early postoperative recurrence include smoking, absence of prophylactic therapy, perianal location, previous intestinal surgery, resected specimen with granulomas, penetrating disease at index surgery
  • Diagnosed by ileocolonoscopy performed within 6 months following surgery 
  • Prevented with thiopurines, anti-TNFs, high-dose Mesalazine, or imidazole antibiotics
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