Inflammatory Bowel Disease (IBD) - Samir Pandya: Update Course 2014
With Dr. Samir Pandya · StayCurrentMD
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Ulcerative Colitis 4 items
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What the experts said
Children presenting with Crohn's disease for the first time with a perianal or perirectal abscess often have non-colonic small intestinal disease.
Perianal abscesses in Crohn's disease are unlikely to heal without fecal diversion because bowel continuity slows healing.
Modern TNF inhibitor drugs are effective at healing perianal disease in Crohn's, potentially allowing avoidance of fecal diversion in selected patients.
Patients and parents would rather deal with a chronic perianal problem than manage a stoma.
Most Crohn's perianal abscesses are not single; when draining a perianal abscess in Crohn's disease, there are usually several fistulas present.
Setons are very effective for perianal fistulas and should be used more often in pediatric surgery than they currently are.
It is less morbid to perform laparoscopic diversion in 15% of patients whose perianal disease fails to heal than to give 100% of patients an ostomy upfront.
Crohn's patients can develop peristomal fistulas as a complication of stoma creation.
Crohn's disease affects the entire GI tract as a chronic disorder, even when only one segment shows active stricturing disease.
A cutting seton requires 360-degree tension on tissue to actively divide it, whereas a non-cutting seton is placed loosely to allow drainage and gradual fibrosis without active cutting.
For duodenal Crohn's strictures, endoscopic and fluoroscopic dilation combined with Remicade can be effective, making the stricture more pliable and allowing weight gain.
Isolated terminal ileal Crohn's disease may be a separate disease entity from perianal or diffuse Crohn's disease because it behaves very differently, with prolonged remission after resection.
Patients with isolated terminal ileal Crohn's disease should be considered for earlier resection before starting Remicade because of the favorable long-term outcomes after resection.
Pediatric IBD patients referred for surgery are often in horrible nutritional shape because GI physicians view surgery as failure and carry patients on medical therapy for too long.
Patients with severe ulcerative colitis who are emaciated, hypoalbuminemic, on steroids, and in poor nutritional status often require three-stage surgery: subtotal colectomy with end ileostomy, then subsequent J-pouch creation.
Patients with ulcerative colitis recover incredibly fast after subtotal colectomy, much faster than after the subsequent J-pouch operation.
The best ulcerative colitis patients ever look is when they have their end ileostomy after subtotal colectomy, before J-pouch creation.
Ongoing rectal bleeding from the rectal stump after subtotal colectomy for ulcerative colitis is rare but can be managed with local therapy.
Endorectal dissection technique (similar to Hirschsprung surgery) can be performed safely for ulcerative colitis J-pouch even in relatively sick patients, as long as a diverting ileostomy is created.
Continued bleeding from the rectal stump after subtotal colectomy for ulcerative colitis can force earlier-than-anticipated completion of the J-pouch procedure.
Between stage 1 and stage 2 of ulcerative colitis surgery, patients often gain 20 to 30 pounds, which can make the subsequent operation technically harder.
In a review study published recently, CT enterography is more accurate than MR enterography for Crohn's disease, though institutional radiologist expertise determines which modality performs better in practice.
Contrast-enhanced ultrasound has sensitivity and specificity as high as 100% for Crohn's disease in previously undiagnosed patients, and above 95% in patients with known diagnosis, according to the Peloda study published in Pediatrics 2013.
Contrast-enhanced ultrasound is only available for clinical use in Europe at present and has not been approved by the FDA.
In Europe, ultrasound is the first-line imaging choice for Crohn's disease, followed by MR or CT enterography, whereas in the US, MR/CT enterography is first-line.
MR enterography provides information about the chronicity of Crohn's disease strictures, helping determine whether a stricture is chronic and fibrotic (unlikely to resolve with medication) or potentially responsive to medical therapy.
Rectal advancement flap for Crohn's perianal fistula is only appropriate in the setting of no active proctitis, and results diminish with time.
Even with permanent fecal diversion, as high as 40% of Crohn's patients have recalcitrant perianal disease as they reach adulthood.
Isolated ileocecal Crohn's disease in teenagers can have recurrence-free intervals as long as 10 to 15 years after resection, allowing symptom-free passage through puberty into adulthood.
If a patient has received infliximab within the last 6 weeks before surgery for ulcerative colitis, there is evidence (both adult and pediatric) that a three-stage approach should probably be used due to increased complication risk.
At 2 years follow-up, there is hardly any difference in bowel frequency between straight ileoanal anastomosis and J-pouch (10 cm J-pouches) for ulcerative colitis, based on a series of 120-130 straight and 110-115 J-pouch patients.