One or TwoStage Operation the Value of Seton Drainage
After the abscess is incised and drained as previously described, the fistulous tract should be drained using a seton drainage 21 . Two or three 4-0 or 5-0 non-absorbable monofilament sutures are placed from the incision of the abscess along the tract to the primary orifice Fig. 2 . They are then tied separately and loosely without tension to avoid pain and skin damage. The seton will allow drainage and promote fibrosis around the fistulous tract. In cases of Crohn's disease, setons can be used...
Massive Bleeding
Massive bleeding from the large intestine that requires immediate surgical treatment is very rare in Crohn's disease. It affects 1.3-1.9 of all patients 91, 95 , and 12 of all cases of bleeding from a digestive tract in patients with Crohn's disease 96 . Massive bleeding occurs in states of severe exacerbations, or a severe form of the disease such as toxic fulminant colitis. It is necessary to locate the site of massive bleeding because as opposed to ulcerative colitis, its location is well...
Introduction Mtj
Surgery continues to play a major role in the management of ulcerative colitis because it may save the patient's life, eliminate the long-term risk of cancer, and most importantly, eradicate the disease. Surgical treatment of ulcerative colitis still remains a challenge for the surgeon despite growing knowledge about the disease and advanced surgical techniques. Optimal timing for surgery is the mainstay of a good outcome and is as important as the quality of surgery. Although as many as one...
Fistulae Management
Currently, there are no data supporting the role of endoscopy as primary treatment of fistulising Crohn's disease. Nevertheless, aside from guiding medical and surgical therapy of a fistula, endoscopy may indirectly and directly impact the treatment of fistulising Crohn's disease 58 . Indirectly, endoscopy may allow for dilation of obstructing strictures that prevent the closure of the fistula. Directly, may treat the fistula via an injection of fibrin-based sealants or anticytokine therapy. A...
Microscopic Features of IBD
Changes in UC usually begin in the rectum and may extend proximally to involve a variable length of and sometimes, the entire colon pancolitis . The mucosa shows intense and diffuse inflammatory cell infiltrate, crypt abscesses, mucin depletion and surface ulceration, especially in active colitis where it is characterised predominantly by cryptitis neutrophils into crypt epithelium , and crypt abscesses neu-trophils within the crypt lumen 54 . Superficial broad ulcerations occur and, when...
Urinary Tract Calculi
The risk of developing urinary tract calculi is 10-100 times greater in patients with IBD than in the general population Fig. 1 3 . The reported incidence ranges from 1 to 25 1-3, 6, 10-12 . The metabolic derangement leading to this complication can be either related to the disease itself or a consequence of its treatment. Patients with CD are much more affected than those with ulcerative colitis UC 10,13 , and the risk is increased after surgery. Calculi are primarily composed of calcium...
Indications Vwr
The choice of the ideal surgical procedure for treating these patients is based upon the following considerations - the need of definitive treatment with a one-stage procedure that allows a complete removal of the diseased tissue and avoids the risk of cancer. - The possibility of restoring the anatomy as well as the bowel function and the faecal continence. - The outcome and the complications of different surgical procedures. - The patient's skills in managing the new condition and coping with...
References Yza
1. Guindi M, Riddell RH 2004 Indeterminate colitis. J Clin Pathol 57 12 1233-1244 2. Leichtner AM, Jackson WD, Grand RJ 1996 Crohn's disease. In Walker WA, Durie PR, Hamilton JR et al eds Pediatric Gastroentestinal Disease. St. Louis, Mosby, pp 692-711 3. Hanauer SB, Sandborn W 2001 Management of Crohn's disease in adults. Am J Gastroenterol 96 635-643 4. Glickman RM 1998 Inflammatory bowel disease ulcerative colitis and Crohn's disease. In Fauci AS et al eds Harrison's textbook of internal...
Toxic Colitis
Toxic colitis, with or without megacolon, is an emergent life-threatening complication of inflammatory bowel disease. Its overall incidence in patients with ulcerative colitis is about 10 27 . Although in the past, toxic colitis was thought to be a rare complication of Crohn's disease compared with ulcerative colitis, recent studies have shown that Crohn's colitis is the etiology in approximately 50 of the cases 28 . The overall incidence of complicated Crohn's disease is about 6 , with an...
Enteric Nervous System the Brain of the Gut
Our immune system is closely related to the axis gut-brain through the enteric nervous system ENS . Nerves from both the brain and the spinal cord of our colitic or potentially colitic patients interact with structures and substances situated and produced in the bowel wall in both health and in disease. What we feel and what we think, what we hope and what we fear, is communicated to the above-mentioned enteric immune and nervous system and vice versa through the transport of cranial sensation....
References Soa
1. Das KM 1999 Relationship of extraintestinal involvements in inflammatory bowel disease. Dig Dis Sci 44 1 1 -13 2. Bernstein CN, Blanchard JF, Rawsthorne P et al 2001 The prevalence of extraintestinal diseases in inflammatory bowel disease a population-based study. Am J Gastroenterol 96 4 1116-1122 3. Snook JA, de Silva HJ, Jewell DP 1989 The association of autoimmune disorders with inflammatory bowel disease. Quart J Med 269 835-840 4. Brandtzaeg P, Halstensen TS, Kett K 1992 Immunopathology...
Contributors
Donato F. Altomare Coloproctological Unit Department of Emergency and Organ Transplantation General Surgery and Liver Transplantation Unit University of Bari Bari, Italy Department of Colorectal Surgery and Surgical Pathology Stepping Hill Hospital Trafford Healthcare Trust Manchester, UK Luciano Alessandroni Department of Surgery S. Camillo Hospital Rome, Italy Giampaolo Angelini Unit of Digestive Endoscopy Policlinico G.B. Rossi University of Verona Verona, Italy Department of Clinical...
Restorative Proctocolectomy 1
After placement of trocars and survey of the abdomen, complete mobilisation of the intraabdominal colon and terminal ileum up to the inferior border of the duodenum is accomplished. The distal ileum and mesenteric vessels are divided intracor-poreally. With the patient in Trendelenburg position, the rectum is circumferentially dissected down to the pelvic floor and transected with an articulate linear stapler at a level confirmed by digital examination. Fig. 12. Laparoscopic total colectomy...
FAP History Through a Patients Story
Gian Gaetano Delaini, Gianluca Colucci, Filippo Nifosi This is the story of Rosa Gallo, a young and bright student of medicine, who died of Gardner's syndrome at 21 years of age this story allows us to more easily explain the history of the disease, the various aspects of which aetiology, clinical history, diagnostic and therapeutical approach are extensively covered in several chapters of this book. Rosa Gallo was born on 6 August 1982, second born of the Gallo family, 4 years younger than the...
Genetics of Dysplasia
Although several other studies have evaluated immunohistochemical findings in these two groups of lesions DALM vs. sporadic adenoma , none have been shown to be useful in this differential diagnosis Table 4. Immunohistochemistry in DALM vs. sporadic adenoma Table 4. Immunohistochemistry in DALM vs. sporadic adenoma 25,26 . However, some investigators have suggested that IBD-associated adenoma-like DALMs has a higher degree of p53, and a lower degree of nuclear beta-catenin and bcl-2 staining in...
Bone Disease in IBD
Reduced bone mineral density BMD is frequently associated with Crohn's disease CD . Early studies have described a high prevalence of osteopenia a T-score of -1 or lower and osteoporosis a T-score of -2.5 or lower in inflammatory bowel disease IBD . Uncontrolled studies gave a prevalence of severe demineralisation determined by dual-energy absorp-tiometry Z-score of lower than -2 or T-score of lower than -2.5 that ranged from 18 to 42 , while larger studies with a healthy control group showed...
Pelvic Sepsis
Pelvic abscess is usually the result of a leak or disruption of the ileoanal anastomosis, leak from the pouch suture line, or an infected haematoma. The prevalence of postoperative pelvic sepsis varies between 5 and 25 40-42 , this wide range being partially attributable to the lack of a standard defini tion. Symptoms and signs include fever, anal pain, tenesmus, purulent discharge, bleeding from the anus and leukocytosis. Diagnosis may be established by examination under anaesthesia alone or...
Operative Technique Vwi
The initial incision, abdominal exploration, mobilisation and dissection of the colon are similar to that Fig. 8. Restorative proctocolectomy J-pouch and mechanical end-to-end ileo pouch-anal anastomosis IPAA for total colectomy. When the colon has been full mobilised and the mesentery has been divided, the patient is placed in a steep Trendelenburg position. The presacral space is entered by dividing the left and right pararectal peritoneum. The plane is developed posteriorly and laterally....
References Xkz
1. Frielle FA, Santoro G, Pemberton H 1996 The management of perianal Crohn's disease. Int J Colorectal Dis 11227-237 2. Singh B, Mortensen Jewell DP, gbrge B 2004 Perianal Crohn's disease. Br JSurg 91801-814 3. Solomon MJ 1996 Fistulae and abscess in symptomatic perianal Crohn's disease. Int J Colorectal Dis 11222-226 4. Parks AGGrdon PH, Hardcastle D 1976 A classification of fistula-in-ano. Br JSurg 631-12 5. American gastroenterological Association 2003 American fistroenterological...
Stapled Ileal PouchAnal Anastomosis
Performing stapled ileal J-pouch anal anastomosis is by far the easiest method with respect to mesenteric length, because in this situation, the transanally placed stapler pushes the perineum towards the abdomen and small-bowel mesentery, reducing the length needed by several centimeters compared to hand-sewn techniques. Purse string sutures are not reliable and frequently are placed incorrectly. Because of this, incomplete doughnuts are common. I prefer to use a triple-staple approach, in...
Elemental Diet Bowel Rest and Parenteral Nutrition
Only anecdotal experience exists on the use of elemental diets and total parenteral nutrition in fistulizing CD. Calam et al. 69 reported on six patients in whom an elemental diet was used specifically to treat perianal fistulae in Crohn's disease. Four improved with an elemental diet, but fistulae only healed completely in one patient. No studies specifically examined total parenteral nutrition in perianal CD. The use of elemental diets or total parenteral nutrition for fistulizing CD is...
Anorectal Stricture
Chronic anorectal abscesses, fistulae, ulcers or inflammation may lead to an anorectal stricture. Three varieties have been described 1. Short, annular strictures less than 2 cm in length, resulting in diaphragmatic deformity. 3. Strictures secondary to dysfunction atrophy. In a series of 44 patients, Linares et al. 29 reported approximately 50 of the strictures as being located in the rectum, 33 in the anus, and the remainder in the anorectum. They also found that most of these patients had...
Nnsteroidal AtiInflammatory gents for Colon Cancer Prevention
Colon cancer prevention has now focused on novel targeted therapies, such as non-steroidal anti-inflammatory agents NSAIDs . Aspirin, an inhibitor of COX-1 and -2, has been studied in several large randomised studies, but the effect on colorectal cancer prevention is unclear. The US Physician's Health Study, which enrolled 22 071 physicians as participants, reported that aspirin had no effect on the incidence of polyps or colon cancer 3 . However, Baron et al. conducted the Aspirin Folate Polyp...
Anal Skin Tags and Haemorrhoids
Anal skin tags are typically asymptomatic and present problems only when they interfere with perianal hygiene Fig. 5 . They are more prominent with active intestinal disease. Approximately 25 resolve spontaneously, generally after remission of concomitant bowel disease. These tags should not be removed Fig. 5. Anal tags with ulceration and tissue inflammation Fig. 5. Anal tags with ulceration and tissue inflammation because that may result in an unhealed wound, a chronic ulcer or perianal...
New Endoscopic Techniques
New endoscopic techniques are being introduced to improve early identification of even minimal lesions and to take targeted biopsies in suspicious areas. These techniques do not replace colonoscopy but are second-level examinations 21 . Endoscopic dye-spraying can improve dysplasia detection 7, 19 . This procedure involves the application of a mucosal stain or pigment, usually by injection through an endoscopic spray catheter. Chromoendoscopy improves the detection of minimal colonic lesions,...
Hull T.l.1996 Work On Ileostomy
1. Schraut WH, Medich DS 1997 Crohn's disease. In Greenfield LJ, Mulholland M, Oldham KT et al eds Surgery scientific principles and practice, 2nd edn. Lippincott, Philadelphia 2. Kodner IJ 1997 Perianal Crohn's disease. In Allan RN, Rhodes JM, Hanauer SB et al eds Inflammatory bowel diseases, 3rd edn. Churchill Livingstone, New York, p 863 3. Platell C, Mackay J, Collopy B et al 1996 Anal pathology in patients with Crohn's disease. Aust N Z J Surg 66 5-7 4. Solomon MJ 1996 Fistulae and...
Peculiar Aspects of Gastroenteric ExtraColonic Manifestations of FAP
Among the possible extra-colonic manifestations are upper gastroenteric lesions, stomach polyps 25-60 of the patients and duodenal polyps 24-73 19-21 . Hyperplastic polyps are commonly observed at a gastric level, whereas at a duodenal level and in the Vater's ampulla we mostly have real adenomas which are also subject to the rule of adenoma-carcinoma progression. Therefore, periodic endoscopic surveillance of the upper gastroenteric tract with possible removal of duodenal adenomas is...
References Yzh
1. Sonnenberg A 1992 Disability and need for rehabilitation among patients with inflammatory bowel disease. Digestion 51 168-178 2. Powell-Tuck J, Garlick PJ, Lennard-Jones JE, Waterlow JC 1984 Rates and whole body protein synthesis and breakdown increase with the severity in inflammatory bowel disease. Gut 25 460-464 3. Smith RC, Burkinshaw L, Hill GL 1982 Optimal energy and nitrogen intake for gastroenterological patients requiring intravenous nutrition. Gastroenterology 82 445-452 4....
Balloon Dilatation
The stenosis of the small intestine is one of the typical symptoms of CD. The standard treatment should be strictureplasty or resection of the affected part 34 . The less common clinical manifestation is large-intestine stricture, which is diagnosed when a colonoscope of a standard diameter 13-13.6 mm cannot be inserted through the affected part of the intestine. The clinical manifestations of the stricture include flatulence, tenesmus when the stricture is localised near the rectum ,...
References Ibo
1. Gordon P, Nivatvongs S 1999 Principles and practice of surgery for the colon, rectum, and anus. Quality Medical, St. Louis, MO, USA 2. Milsom JW, Hammerhofer KA, B hm B et al 2001 Prospective, randomised trial comparing laparoscopic vs. conventional surgery for refractory ileocolic Crohn's disease. Dis Colon Rectum 44 1-9 3. Dunker MS, Stiggelbout AM, van Hogezand RA et al 1998 Cosmesis and body image after laparoscopic-assisted and open ileocolic resection for Crohn's disease. Surg Endosc...
Ultrasonographic Assessment of Perianal Crohns Disease
Accurate identification of all loculate purulent areas and definition of the anatomy of the primary fistulous tract, secondary extensions and internal opening is crucial for the treatment plan. EAUS has been demonstrated to be a very helpful diagnostic tool in accurately assessing all fistula or abscess characteristics 8-11, 16, 17 . Ultrasound examination with the 2050 transducer is generally started using 13 MHz, changing to 12 MHz or 9 MHz to optimise visualisation of the deeper structures...
References Tci
1. Steinberg DM 1973 Abscess and fistulae in Crohn disease. Gut 14 865-869 2. Rankin GB 1979 National cooperative Crohn's disease study extraintestinal manifestations and perianal complications. Gastroenterology 77 914-20 3. Farmer RG 1975 Clinical patterns in Crohn's disease a statistical study of 615 patients. Gastroenterology 68 627-635 4. Sachar DB, Bodian CA, Goldstein ES et al 2005 Is perianal Crohn's disease associated with intestinal fis-tulization Am J Gastroenterol 100 7 1547-1549 5....
Conclusion Row
FAP and other polyposis syndromes are generalised disorders with ramifications throughout the body. Early diagnosis by recognition of at-risk individuals and proctoscopic surveillance is important in preventing cancer. Surgical options now available can eliminate the risk of colorectal cancer and provide a good functional outcome without a permanent ileostomy. Ongoing surveillance programmes are important because there is still a risk of dying of extra-colic manifestations of the disorder....
References 1
1. Langholz E, Munkholm P, Nielsen OH et al 1991 Incidence and prevalence of ulcerative colitis in Copenhagen county from 1962 to 1987. Scand J Gastroenterol 26 1247-1256 2. Munkholm P, Langholz E, Nielsen OH et al 1992 Incidence and prevalence of Crohn's disease in Copenhagen county, 1962-1987 a sixfold increase incidence. Scand J Gastroenterol 27 609-614 3. Gower-Rousseau C, Salomez JL, Marti R et al 1994 Incidence of inflammatory bowel disease in northern France. Gut 35 1433-1438 4. Moum B,...
References Emp
1. Ullman TA 2005 Preventing neoplastic progression in ulcerative colitis. J Clin Gastroenterol 39 4 S66-S69 2. Sjoqvist U 2004 Dysplasia in ulcerative colitis clinical consequences Langenbecks Arch Surg 389 5 354-360 3. Itzkowitz SH, Present DH 2005 Consensus conference colorectal cancer screening and surveillance in inflammatory bowel disease. Inflamm Bowel Dis 11 3 314-321 4. Judge TA, Lewis JD, Lichtenstein GR 2002 Colonic dysplasia and cancer in inflammatory bowel disease. Gastrointest...
Flogistic and Fistulous Disease
Flogistic mass is a frequent finding in Crohn's patients, in particular in recurrent disease. Large palpable mass per se, especially if associated with complex fistulous disease or with a frozen abdomen, are often considered to be a contraindication to laparoscopy 4, 7, 9 10 , whereas a mininvasive approach is considered possible even after previous multiple surgeries 11, 12 . When a flogistic mass is present with thickened mesentery, the size of the minilaparotomy depends on the size of the...
References Obi
1. Ekbom A, Helmick C, Zack M et al 1990 Increased risk of large bowel cancer in Crohn's disease with colonic involvement. Lancet 336 357-359 2. Langholz E, Munkholm P, Davidsen M et al 1992 Colorectal cancer risk and mortality in patients with ulcerative colitis. Gastroenterology 103 1444-1451 3. Choi PM, Zelig MP 1994 Similarity of colorectal cancer in CD and UC. Gut 35 950-954 4. Gyde S, Prior P, Dew MJ et al 1982 Mortality in ulcerative colitis. Gastroenterology 83 36-43 5. Munkholm P,...
Osteomas and Dental Abnormalities
Osteomas are the most common accompanying bone lesion seen in FAP, and the first extra-colonic lesion to be associated with FAP 123, 124 . Osteoma is a benign neoplasm of bone tissue that increases in size by slow continuous osseous growth and consists of well-differentiated compact or cancellous bone. It is a painless tumor and has no malignant potential. Since the mandible and skull are the most common locations, asymmetry of the maxillofacial region is typical. In children, it may precede...
Surgical Treatment of FAP
As FAP is 100 precancerous, colectomy is recommended. Treatment of FAP is influenced by the nat ural history of the disease, which is variable. If patients are left long enough without colectomy, they will all develop carcinoma. The sooner is patient diagnosed, the better prognosis could be if colectomy is performed. There are three possibilities of surgical treatment. Each has its pros and cons Total colectomy with permanent ileostomy in cases of malignancy in the lower rectum Total colectomy...
NSAIDs and Desmoid Tumours
Several reviews 51-53 have summarized the intriguing and accumulating evidence that nonsteroidal anti-inflammatory drugs NSAIDs have potential as anti-cancer drugs. NSAIDs have been shown experimentally to stimulate apoptosis and to inhibit angiogenesis, two mechanisms that help to suppress malignant transformation and tumour growth. The mechanism of action common to NSAIDs is the inhibition of cyclooxygenase COX enzymatic conversion of the polyunsaturated fatty acid arachi-donic acid produced...
Sepsis
Sepsis can be defined early or late. The incidence of such complications varies in 5-25 of cases after RPs 4, 5 , and approximately half of these are responsible for the failure of the surgical operation. The majority of the cases depend on the anastomot-ic complications regarding the pouch anal or regarding the proximal ileum to the pouch. After modification via mucosectomy's technique, which is used preliminarily to remove all disease prone mucosa , the sepsis rate is remarkably reduced. The...
Ureteral Obstruction
This event is not rare and in most cases is not secondary to renal calculi. Although some signs of unilateral renal stasis have been demonstrated in almost 50 of IBD patients, who for various reasons have an intravenous pyelogram 83 , the reported incidence of ureteral obstruction with associated hydronephrosis is 3.1-14.3 in patients with CD 1, 3, 6, 84-86 and 6.8 in those with UC 84 . However, these percentages might be underestimated, considering that this condition is often asymptomatic or...
Equipment
The most widely used EAUS system is the B-K Medical scanner Pro-Focus 2202, B-K Medical A S, Mileparken 34, DK-2730 Herlev, Denmark , with a Fig. 4. B-K Medical anorectal probe type 1S50 Fig. 4. B-K Medical anorectal probe type 1S50 hand-held rotating endoprobe type 1850, which gives a 360 axial view of the rectal wall Fig. 4 12 . The radial probe has a 24-cm metal shaft with a rotating transducer at its tip. This 8539 transducer has a frequency range from 5 MHz to 10 MHz with a focal length of...
Definition and Classification of Dysplasia in Ulcerative Colitis
Dysplasia is defined as an unequivocal neoplastic change that is intraepithelial and within confinement of the gland basement membrane or as an unequivocal neoplastic alteration of the colonic epithelium. It may be a marker of carcinoma or may itself be malignant and associated with invasion into the underlying tissue 8 . It is important to realise that, for a very important and practical reason, diagnosing colonic dysplasia is one of the most challenging exercises that the surgical pathologist...
Anal Fistulae
M.L. Corman observed that, More surgeons' reputations have been impugned because of problems with fistula operations than from any other operative procedure 47 . In general, anal fistulae present symp-tomatically Fig. 6 . In Crohn's disease, they have the reputation of being difficult to treat with a high rate of recurrence. Patients are more concerned with postoperative incontinence, even if minor. Many authors advise the most cautious attitude in regards to surgical treatment 12, 18, 22, 47 ....
Preoperative Stoma Site Marking
It is extremely important to have the patient marked for a stoma site preoperatively 4 . This is most true in the obese patient and in the patient that has had previous open surgical incisions. If the patient should have a problem with the distal anastomosis and require diversion for longer than the normal 8 weeks postoperatively, it is imperative to have a stoma located in a location where the appliance will be able to adhere for at least 2-3 days. In patients in whom the ileal J-pouch anal...
Accuracy
Imaging with EAUS has been shown to be a useful method accuracy ranging from 63 to 100 for evaluation of perianal abscesses and fistulae in CD 7-11,13,18 . Van Outryve et al. 8 reported that the routine proctological examination showed Crohn's lesions in 30 of patients and EAUS performed with a linear probe detected anorectal anomalies in 75 of patients. Moreover, EAUS was superior to CT scan in the study of pararectal and para-anal abscesses and fistulae. Schratter-Sehn et al. 19 demonstrated...
References Qhv
1. Irvine EJ, Feagan B, Rochon J et al 1994 Quality of life a valid and reliable measure of therapeutic efficacy in the treatment of inflammatory bowel disease. Gastroenterology 106 287-296 2. Alstead EM, Nelson-Piercy C 2003 Inflammatory bowel disease in pregnancy. Gut 52 159-161 3. Moody G, Probert G, Srivasta E et al 1993 Sexual dysfunction amongst patients with Crohn's disease, a hidden problem. Digestion 52 179-183 4. Moody G, Mayberry J 1993 Perceived sexual dysfunction amongst patients...
Introduction Nbt
The development of fistulae is a common complication of Crohn's disease CD . The lifetime risk of fistula development in patients with CD has typically been reported to range from 20 to 40 . The reported incidence of fistulizing CD from referral-based case series ranged from 17 to as much as 85 1-3 . The probability of internal fistulae was particularly high in patients with perianal disease who presented a relative risk of 3.4 compared to patients with different localizations 4 . Over time,...
Rectovaginal Fistulae
Rectovaginal fistulae occur in 3-10 of women with Crohn's disease 74, 75 . Most of these fistulae originate from an anterior rectal ulcer eroding into the vagina, which usually occurs in the midportion of the rectovaginal septum. These fistulae are the most difficult to treat and have a poor prognosis 76-78 . Less commonly, these fistulae may arise from an infected anal gland and they may travel superficially, through, or above the sphincters. Bartholin's abscesses may also fistulise to the...