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.

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

  • Temporary ileostomy
  • Ileal pouch-anal anastomosis (IPAA) procedure: Gold standard for surgery
  • 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
  • Total proctocolectomy with permanent ileostomy

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

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 the 1st year following surgery 
  • Prevented with thiopurines, anti-TNFs, high-dose Mesalazine, or imidazole antibiotics
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