Inflammatory Bowel Disease: Update Course 2014

I thought I would just jump right in and we'll talk about a, a few cases here. Um, so we have a 12 year old male with a 3 day history of rectal pain, poor PO tolerance, and vomiting and diarrhea. He's been diagnosed with Crohn's for 4 months and managed with, as you can see, uh, uh, 6-MP, Pentasa, Cipro and Flagyl. He's had some weight loss. And he has a perianal fluctuant mass that's tender at the 8 o'clock position in dorsal lithotomy. He has a white count and a sed rate. So for the Panel and the crowd, um. Which of the following modalities can be used to help the diagnosis of fibrostenotic and fistulizing Crohn's? What is the, what is the, what, what is the panelists, uh, uh, first choice here for this patient? So we do, we do an MRE, so do we. We do an MRE. Although I think there's some data to suggest that a CT enterography is actually more accurate than an MR enterography, but I think it probably in our institution, at least, I think it depends on the expertise of the radiologists, and ours are much more comfortable with an MRE, it's, it's more accurate in, in a review study that was published recently. Is there anyone here that's not getting either uh an MR enterography or a CT enterography? Do people do small bowel follow-throughs instead with contrast? I think you still can do that. It's not a bad study. Uh, I think the, the, the kids that show up with Crohn's disease for the first time with a perianal, perirectal abscess, uh, will often have non-colonic disease but small intestinal disease, and I'm not sure why it happens that way. So you can pick, you can pick up that with a standard small bowel series. And then, then, you know, when you, you, when you go to sort of drain them, you do a good uh colonoscopy. The problem with that, I think, is that if it's negative, then you're going to say, well, we just, we need a better study. We're going to get an MRI. Has anybody used ultrasound? I've never. Uh, Samir, is that what you're using, or well, that's not what I'm using, but I see Philip is back on. Want to ask Philip what are his thoughts about contrast, uh, uh, so Philip needs to call, uh, into the phone line. So he's, uh, give us a minute for him to call and we can go back to him. Oh, he's called in. The reason I brought this up is, um, so interestingly enough, in the, uh, in the literature review that I did in preparation for this, uh. Our European colleagues actually use a lot of contrast enhanced ultrasound. And um it's only available for clinical use in Europe at present. It's not been approved by the FDA and um in their findings, uh, in this Peloda study that was published in pediatrics in 2013, they have as high a sensitivity and specificity of contrast enhanced ultrasound to as high as 100%. Uh, this is in previously undiagnosed patients, above 95% in those who have a known diagnosis. So, that was, that's been a very radical change ever since I got out of training, which was not that long ago that it seems that in Europe, uh, there are, there's a fair amount of use of ultrasound in, uh, Crohn's disease to the point that if you see this algorithm, um, in Europe, it seems that the first line, uh, choice is, uh. Ultrasound followed by MROCT as we would do it in the US. Which I thought was kind of interesting. Mhm. Phillip now Philip, you there? No, it still doesn't show his name up yet. You were gonna make a comment. Yeah, well, I was just gonna say one of one of the reasons that our radiologists have advocated MR enterography is because that in addition to giving you um an image of the stricture, it also gives you an idea for the chronicity of disease and. So it gives you that piece of data to, you know, tell you, well, you know, is this a stricture that's chronic fibrotic and is never going to resolve no matter how much you hammer them with medication, or is this something that potentially, you know, could resolve with um medication. I think Philip was trying to tell us something, but Well, we couldn't, I couldn't read the sign. So Dan, uh, Dan said he'd start with a CT and progress to MRE. That. OK, well, it was, uh, So we'll move on to the uh what the MRE found, and the MRE found we found a grade 2 insenteric fistula with the perianal, let's keep going. Sorry, Samir, keep going, yeah, as well as the 8 centimeter. Samir, are you there? Yeah, I'm here. So, uh, Mark, Mark, we've, there's been an audio switch, switch. So I've been trying to tell you guys we, we can only hear stuff and we can't hear the audio of the program. I can hear Samir. I can hear you, yeah, I'm hearing. So the central guys up here can't hear. The side guys came. Yeah, I'm hearing now. I'm hearing it right. The side guys can hear. Is is your stuff on the side? No, we can hear them backstage. All right, Samir, go ahead. Go ahead, Samir, sorry, technical issues. No worries. So we have a grade 2 insenteric fistula with an abscess along with an 8 centimeter stricture in the terminal ileum. So with this patient, in combination with medical therapy, the most appropriate surgical approach for this patient with regards to his perianal abscess and fistulizing and fibrostenotic Crohn's disease would be. IND fistulotomy and ileocecal resection with reastomosis. IND cutting Seton ileal strictoplasty, IND non-cutting Seton with subsequent ileocecal resection and reastomosis or IND and placement of non-cutting cton with endileostomy. Has the patient had previous therapy? And is the bowel, is the bowel proximal to the stricture dilated? So those are great questions. So this, uh, what I was trying to hit here is a patient that's been treated for about 4 months and maximized on his, uh, um, medical therapy, um, and, uh, does, we will say for argument's sake that yes, there is dilation, uh, proximal to the stricture. But is he symptomatic from that? Well, he had an 18 pound weight loss in the last 4 months. Yeah. So for me, those are indications to do the ileal resection. I, I guess for me, the issue then would be what is, what is the, uh, um. Do you think you need to divert the patient to get the fistula to heel, uh, the perineal fistula to heel, and I, I. That's a difficult case because I, um, you want to do it with one operation, obviously, but I guess I would probably lean more if you didn't have. Depending on what his medical therapy had been, if he had not been on anti-TNF drugs and such, then I would probably do the ileal resection and then with the primary anastomosis and then start him on those medications. I, I agree. I think the anus is showing you what's kind of going on on the inside, so do something limited there and then resect the. The ileum for the reasons you mentioned. So a non-cutting ston would be my, I'm not sure what number that is, but that would be non-cutting, but I'm not, I'm not sure that that perianal abscess is going to heal without some diversion temporarily. I think you absolutely have to resect the strictured ileal ileocecal area. You've got to drain the abscess, but those abscesses, even when you get rid of what's the gross disease in the, in the in the bowel. May not heal if they're not diverted. I agree. And so, you know, you know, so you could resect, do a temporary end ileostomy for the mucous fistula, let that drain the abscess, let it heal, and then cook him back up. He will probably get recurrent disease at some later date, but he may go several years without that. So, but I don't think if you just resect and do a primary anastomosis and then drain the abscess, that abscess is going to have a great chance of healing. So this patient. So would you, would you advocate diversion for a, for the first time perianal abscess, or would you do that for, um, multiple abscesses or recurrent disease? I, I think in this particular case, I would go in and, uh, laparoscopically maybe resect the, uh, ileum and do an end ileostomy with the, with the mucous fistula from the, from the, uh, right colon, wherever you want. To bring it out, drain under the same anesthetic, drain the rectal abscess, uh, and do all of it at once. And I think you can do that in something like this, and then you'll look at closing that, uh, stoma in 3 to 6 months, something like that. See, the only patients I've diverted, though, have been, had distal colon disease as part of the perianal disease. So, as much as I hate to ever disagree with you, Doctor Corn, I don't, I think I would not divert this patient. Because it's small bowel, I think you can resect it, bring it back together, you know there's going to be Crohn's there. Plus the new drugs are so good at healing some of the, but the one thing that's going to slow down the healing of the perianal abscess is going to be bowel continuity. And I think these are very hard to heal. I mean, if you, you see them, they, they, they take a long time to heal. And if you can speed that up by just doing a stoma at the time you resect, what's the big deal? I think they will clearly, they will clearly heal faster if you do that. I think patients would rather deal with a chronic problem in their bottom than to deal and the parents deal with the stoma. So I would not necessarily divert them unless they had extensive colonic distal colonic disease. But my question is, is there a role? Or just doing a stricture plastic, um, um, rather than you got, you got to, how long is that stricture 6 or 8 centimeters, you can't do a strictureplasty really what size is, I guess my question is if there was a smaller segment that was involved, it was a smaller sig, a smaller stricture, what would you be? When would you consider doing that? And would you do that in the presence of distal disease? I, I think Arnie's method would be the right way, method if there were multiple fistula and you know, multiple little abscesses, single abscess. I think if you resect the disease, use some of the new medications, TNF and all the other stuff. And use the Sean. Seans are very effective, uh, colorectal people use them all the time. We rarely use them. We shouldn't use them more often than we do. And I think for a single one, I think I would probably go with a Sean resection and treat them, but I would bet, I would bet that it's not a single one. I think most of those when you go in and drain a perianal abscess in a Crohn's disease, there are several fistulas there, and there may be one area that bulges the most, and I, I, I think, uh, I don't think you're gonna be able to heal that as well unless you divert them. And I don't think, I'll, I'll tell you, Lou, if I had to deal with a perianal abscess in my butt. Or have her take care of a stoma from a terminal ileum, there's no question which would be easier to take care of. Yeah, uh, I wish I take your point, but it is sort of a surreal experience because Dr. Wolcott's sitting to my left, not saying anything, but I can hear his voice in my mind saying. If you divert everybody, if you give everybody a stoma, everybody has a stoma, and so there might be some patients here that you could get by without a stoma. And I think if you do the resection, put them together and they heal, then, you know, with a seat tongue, then you're great. And if it fails and they're not good, go ahead and do a stoma. Dan, was that you? Yeah, I agree. I don't think. You shouldn't commit 100% of the patients to a stoma, not in today's environment where you might be able to avoid it in 70% of them. That just doesn't make any sense to me. Well then, you've got to go back in if it doesn't work and do another operation. That's right, laparotomy. No, it's laparoscopy laparoscopy, so it's not as big a deal. What's that, Dan? I said, I agree, but it's a laparoscopic operation. It's low morbidity. It's much less morbidity to go in and operate on 15 patients to take down and give them an ileostomy than to give 100 of them an ostomy that's my whole point. And that, they can go a few months with that Seton, and then you can go to a rectal advancement flap to get that fistula to close. Nice little procedure to do. Agree. I think one of the other things also to, uh, to take into account a couple of points is that, uh, if you do do a stoma, there's also peristomal complications that are unique to Crohn's patients as well. They can have fistulas right around the stoma, which is. Good point. But you. Affecting the diseased area before you bring out the stoma. You're going to take out the, bring out the stoma proximal to where there was disease. I mean, well, I mean, my understanding with, uh, is that Crohn's may have one particular segment that's strictured, and that may be the disease segment, but in general, it's the entire GI tract that's affected. It's, It's a chronic disorder. It's going to recur. Yeah, it's going to recur, but at that moment in time there may not be disease in that area. When you're looking with, with the stoma, what you're looking for is to have an immediate maximum chance of healing that fistula. That's how I would look at it. I mean, we've all seen these kids that come in where it looks like a grenade went off in their bottom. That's and I think that's a I think I think that's a different animal. But if you have just a, I mean, I think in this kid with a single, even if it's a large abscess, you give it a shot at healing with drainage and, you know, maybe you do a couple more rounds of the of Remicade or the TNF inhibitors after this other stuff's gone so that the burden of disease is less and maybe it'll work better. Have you ever seen a Crohn's perianal fistula that's a simple one? No. They're hard patients to take care of, and I don't think any of them are. Yeah, yeah, let's carry on. This might go on. Dr. Thorn wants to do a stoma, but cocktail. Are we clear on that? Yes, I use them all the time. I think we're clear on that. All right, so here. So, moving on, so just, uh, uh, look, uh, buying some data from the adult literature, um, what we did, uh, what I did find that we have, the current recommendations from the adult literature is to go ahead with the non-felling COs, which is what most of us have said here. Um, and in their, uh, in their data, the Remicade does use, Exposure in a very wide range of patients, 25 to 100%. The recommendations for the indirectal advancement flap, I heard somebody talk about that earlier, uh, that is only in the setting of no active proctitis, and unfortunately, the, um, The results, uh, diminish with time, uh. So Samir, can I ask you a question because I might change my practice here. So, um, I put in seatons, and the way I learned about cutting seatons, you make them tight so they cut through. I make them loose, but I do see them back frequently, and if it starts eroding its way through, I keep putting silks on them, not tight, so they don't even feel it. It doesn't hurt them, but it causes a little bit enough. So I would love it if it would cut out. I would love if it would erode through and secondarily scar behind. That's the way the sans work. So I don't, I don't want to say that I wouldn't use a a cutting sea time, I just wouldn't do a true cutting sea time where you're. Cutting through fast, I think it's good if it erodes out through. Well, I mean, I, I mean, I guess you use a non-cutting seats on, make it tight, it'll fit through. You pull on it every day. I think that, but I don't think, I don't think that's a bad, I don't think that's a bad thing. I think that's what you're describing is a non-cutting sea. What's that? That's the material doesn't matter if you're using a silk, right? The difference between non-cutting and cutting is how tight you make it. Yeah. And then for cutting for cutting sea tons. Um, I mean, I've seen it done both, both ways, but my understanding is the correct way to do it, yeah, is you got to make this, you got to cut the skin or else it doesn't really come through because the skin is a barrier that it won't cut through. So you get, so I get them to the point where it's at the skin and I take them to the OR for a secondary fistulotomy. That's what I do. So I, if that's a cutting, then I'm doing a, no, initially that's a non-cutting. That's a non-cutting. Yeah, yeah, that's a non-cutting. If you're not making it cut, it's not cutting. I want, no, I want a non-cutting Seton, and I don't want a stoma. If we're going to vote, so nobody here, nobody here if anyone here has ever seen a patient with a cutting, they're not happy. They're not, but again, I want to make sure because that sounds like I want to make sure I'm clarifying, but you're it doesn't hurt non, you can still do a cutting seaton where you just barely add a silk 1 millimeter or more. You're just making your loop smaller as it comes out. Yeah, that's right. That's fine. Oh, I see what you. You don't think my tightening it is making it come out. No, to be cutting, you need to have tension. You need to actually have 360 degree tension on the tissue. You're not that's a non-cut what you're describing is a non-cutting. OK, fair enough. OK. All right, Sam here. Yeah, keep going. Yeah. All right. And then with, uh, just, uh, speaking to Doctor Corn's point that permanent diversion would be good, but even with that, as high as 40% of patients as they get into their adulthood have recalcitrant, uh, perineal disease. Right. So this is a very, uh, very difficult problem, as we all recognize. So in terms of the fibrostenotic, uh, endoscopic dilation for the short accessible strictureplasty for anything that's, uh, under about 5 centimeters or so, and there's a variety of strictureplasties that are described in, in the literature. And then the segmental resection, as we all pointed out, is pretty good for, uh, the prepubertal patients who have had growth delay or, uh, significant, uh, nutritional, uh, weight loss. So, in the interest of time, we'll move on to ulcerative colitis here. Um 11 question, Samir, what would you do for a kid with Crohn's disease who developed duodenal disease? Yeah, I, I recently had a patient with that, and, uh, what I've been, uh, managing this patient with is, uh, a combination of Remicade as well as uh, endoscopic and, and, uh, endoscopy and fluoroscopic control. I've been dilating the duodenal stricture and, uh, I've had to dilate it, uh, dilate it twice. And that has worked out pretty well for him so far. I reimaged him after 3 months of 3 cycles of Remicade, and his stricture is much easily pliable, and he's able to eat and gaining weight. Have you ever seen a duodenal stricture that you could do a stricture of plasty on? Uh, no, I have not. You know, 11 thing about that particular disease in a teenager that is just isolated ileocecal disease is that the experience, and we wrote a paper on this several years ago from Michigan, the experience with when the recurrence comes, and they will eventually recur, can be as long as 10 or 15 years. They may have a very, very symptom-free experience to go through puberty into adulthood. And so it's, they're all going to eventually get disease again, but it may be a while before it comes back. Although I think that isolated TI disease we're going to find is a separate disease from here. I think that there's ulcerative colitistis, Crohn's, and then there's this other disease where it's isolated TI because it behaves very differently from perianal or diffuse Crohn's disease. Well, that's, that's what I'm saying, exactly, yeah, you seem to cure it, but not permanently. Yeah, but they also, I mean, if you follow them into adulthood, it's a different story. They start to act more like other Crohn's patients. Yeah, I think it's, I think it is Crohn's. I mean, it's not ulcerative colitis, and I think they get recurrence, but uh fortunately you can have, they can have a, importantly, that they can go through teenage years, their growth, yeah. So I, I resect those patients earlier because I think that they do really well before I put them on Remicade. I'll resect TI isolated TI disease much earlier than I will. I think there's some evidence that that is probably a reasonable approach. OK, it's here. Go ahead. All right. OK. And by the way, just to let you know, we do have Philip on the line, so if you ever want to ask him a question, he's here. Well, while we're on, uh, uh, talking about Crohn's, Phillip, did you, uh, could you comment on the use of ultrasound in, uh, Crohn's in Europe? Yes, we do in general, as you know, in Europe, use of ultrasound is generally advocated for basically everything, so it's hard to find a patient which gets gets out of the hospital without having had an ultrasound examination for any reason. But in the more sophisticated department of pediatric radiology, I do think that ultrasound for um. Uh, chronic inflammatory, um, bowel disease is, is, is, um, increasingly used, but still I must admit that, uh, still the, the standard um diagnostic tool is the MRI. Thanks, Philip. Thank you, Philip. All right, so we'll go on to the next case. We have a 17-year-old female with a 6 month history of bloody mucoid, diarrhea, and weight loss. She was diagnosed with ulcerative colitis 3 years ago, managed with 5 ASA and prednisone. But recently has required several hospitalizations, high dose corticosteroids, and Remicade. She's had 8 blood transfusions over the last 6 months, and these are her labs. Most appropriate surgical therapy, I would like to pull the panel. What do y'all All right. So, so Samir, is she sick or not sick? She's not dying from, uh, blood loss right now. Not hospitalized, but she, but she, but she's had, is she in the hospital? Is she on steroids, and she's in the hospital. She's on steroids. How long has she had her disease? 6 months. 6 months. Uh, uh, 3 years. I'm sorry, 3 years. Makes a difference. Yeah. So what, what does the panel think? How would you handle this, Doctor? I send it to the army. I'd be doing in Austin. I'll pass that right over to Arnie. Uh, you know, I, I would, I would probably, if she looked in reasonably good nutrition, I'd take her to the OR. I do it, uh, a, uh, subtotal colectomy, uh, and I do a pull-through, and, uh, uh, and, uh, either a J pouch or a straight, you know, did you say J pouch? I've been doing J pouches for the last 10 years. And, and all of them, I've left a little loop, uh, ileostomy. Close it at 6 weeks to 2 months. Would anyone go ahead, would anyone do it without an ostomy in this patient? No, I'm not on steroids in the hospital. And we might even be, I mean, that's what I was saying, how, depending on how sick they were and their nutritional status, you know, I think some of these kids just, you know, it seems to me that the patients that we're getting now from the GI docs are in just horrible shape because they've, it's like we're the last resort. And we think of ulcerative colitis as a surgical disease. They think of it as a medical disease, so we're a failure. Surgery is failure to a GI doctor, so they carry these patients on for so long that by the time you get them, they're emaciated. Their albumin is low, their nutritional status is terrible. They've been on steroids. They've been on everything else, and a lot of these kids, we end up, we do, we do a total pro, you know, we do a total colectomy, or not a total, subtotal colectomy. And do an end ileostomy and then bring them back for the subsequent stages of you do 3 stage, 3 stage if they're sick. I would do the same thing if they're sick, they're getting transfusions, and my experience has been they get better incredibly fast after the subtotal, much faster than after the subsequent J pouch. Yeah, yeah, I think the best they've ever, the best they ever look is when they have their stoma. Right, you know, talk about, so everybody got rid of the disease, well, except you can sometimes have ongoing rectal bleeding in that situation. Yes, that's rare. It happens, but it's can manage that and you can manage it with local therapy, yeah, but I think even in a relatively sick patient you can do that at dissection. I don't know how people like to do the pull through. I like to do it with an indirectal technique like we do with Hirschberg. The adult guys, you know, do it differently, uh, and I think even in a sick patient you can do that safely, even though it could be a little bloody and, and, uh, and you can end up with a lot of friable bowel you're working with. And then as long as you back it up with an ileostomy, they're gonna do great. They, they recover. I literally about a month ago had a 3 year old, one of the youngest I've ever seen. With such severe ulcerative colitis that the rectum felt like tissue paper and the kid was super, super sick. We, we did that just that we were able to do the endorectal pull through and a little J pouch, and the kid was, you know, blossomed after that. So I think that's the patient. I, I had a patient similar and to Max's point, we just did a subtotal colectomy and the child had continued bleeding from the rectal stump until it forced me to go earlier than I had anticipated, and I think that's happened more frequently than we realized. That's why I think you should. Unless you think the kid's just too damn sick, you should try to do the, uh, the pull through, uh, with, with, with whatever you like to do J pouch and, and as long as you got a backup ileostomy and you've got a, uh, a colon out, the kid's gonna get better. Anybody here do a two-stage? I was, well, 11 problem with the three stages, I find they gain, they often gain 20 or 30 pounds. You were talking about that earlier, and then the operation's a little bit harder. Yeah, that's true in between stage 1 and 2. So yeah, I would try to do a two-stage. Who does it laparoscopically? Actually I've done that. Yeah, um, and then, uh, second question is who does a hand sewn anastomosis and who does a staple. So staple double staple technique, double staple. I double staple does double staple depends on their age and size. Yeah, it depends on the age. I think it's hard to do it with, uh, like a 3 year old. Well, I think. So your group has described the technique of reverting the rectum, and you can staple. I didn't think you could do it, but you can. You staple right at the top of the columns, which I guess. There's a 21 stapler that's available, but not, it's not always, uh, in stock, and you got to be sure you have that for the EEA, yeah, the EA part of it, uh, but, uh, uh, no, I, I think a hand sewn is still a pretty anastomosis, but it's a lot easier on your back helping a resident with the stapler. So, OK, um, so smear, any, how many people are doing J pouches versus straight yellow anals? J pouch. Microscopy and really, are we recording this? No, no, no. Look at, you know, you saw that paper that we put together about 3 or 4 years ago in which we took, uh, uh, we had, I don't know, 120, 130 straights and 110 or 15 Jay's, not huge Jay's, you know, 10 centimeter J pouches, and when you looked at 2 years, there was hardly any difference even in bowel frequency. So I think Samir, I think we're out of time. Is there anyone in 60 seconds that has one, a a quick statement, not a whole dissertation I would say one thing if they've had infliximab within the last 6 weeks, there is some evidence, both adult and pediatric, that you should probably do a 3 stage if they, if fair enough if they've gotten to that stage complication. Yeah. Any other comments? That's a good comment. Any other comments? I think 11 more comment that I'll just make is that we all should be cognizant of this new entity, this indeterminate colitis.