Inflammatory Bowel Disease: Update Course 2014
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Children presenting with Crohn's disease and perianal/perirectal abscess often have non-colonic small intestinal disease.
MR enterography provides information about both stricture anatomy and chronicity of disease, helping determine whether a stricture is chronic/fibrotic (unlikely to resolve with medication) or potentially responsive to medical therapy.
For a patient with 18-pound weight loss over 4 months and dilated bowel proximal to an 8 cm terminal ileal stricture, these are indications for ileal resection.
Perianal abscesses in Crohn's disease may not heal without temporary diversion, even after resection of gross bowel disease.
For first-time perianal abscess in Crohn's disease, temporary diversion should be considered via laparoscopic ileal resection with end ileostomy and mucous fistula, with stoma closure planned at 3-6 months.
Diversion is typically reserved for patients with distal colon disease as part of perianal disease, not for isolated small bowel Crohn's with perianal abscess.
Bowel continuity slows healing of perianal abscesses in Crohn's disease.
Patients and parents would rather deal with a chronic perianal problem than a stoma, unless there is extensive distal colonic disease.
Setons are very effective for perianal Crohn's disease and are used frequently by colorectal surgeons but rarely by pediatric surgeons, who should use them more often.
When draining a perianal abscess in Crohn's disease, there are usually several fistulas present, not just a single one.
If resection with primary anastomosis and seton placement fails to heal perianal disease, a subsequent laparoscopic diversion can be performed with low morbidity.
Rectal advancement flap is an option for fistula closure after seton drainage, but only in the setting of no active proctitis.
A non-cutting seton can be progressively tightened by adding silk sutures to make the loop smaller as it erodes through tissue, without causing pain to the patient.
A cutting seton requires 360-degree tension on tissue to actually cut through; progressive tightening without tension is a non-cutting seton technique.
For duodenal Crohn's stricture, management with Remicade combined with endoscopic and fluoroscopic dilation can be effective, with stricture becoming more pliable after 3 cycles of Remicade.
Isolated ileocecal Crohn's disease in teenagers may have recurrence-free intervals as long as 10-15 years after resection, allowing symptom-free passage through puberty into adulthood.
Isolated terminal ileal disease may be a separate disease entity from perianal or diffuse Crohn's disease, as it behaves very differently.
For isolated terminal ileal Crohn's disease, early resection before starting Remicade may be a reasonable approach, as these patients do well and can go through teenage years and growth phase successfully.
In Europe, ultrasound is generally advocated for basically everything, and it is increasingly used in sophisticated pediatric radiology departments for chronic inflammatory bowel disease, though MRI remains the standard diagnostic tool.
For a patient with ulcerative colitis in reasonably good nutrition, subtotal colectomy with pull-through and either J-pouch or straight anastomosis with loop ileostomy (closed at 6 weeks to 2 months) is appropriate.
Patients with ulcerative colitis referred for surgery are often in horrible shape because GI doctors view surgery as failure and carry patients on medical therapy for too long, resulting in emaciation, low albumin, poor nutritional status, and prolonged steroid exposure.
For sick ulcerative colitis patients, a three-stage approach is used: subtotal colectomy with end ileostomy, followed by subsequent J-pouch creation.
Patients with ulcerative colitis recover incredibly fast after subtotal colectomy, much faster than after subsequent J-pouch creation, and often look their best when they have their stoma.
Ongoing rectal bleeding from the rectal stump after subtotal colectomy can occur but is rare and can be managed with local therapy.
Even in relatively sick ulcerative colitis patients, endorectal pull-through can be performed safely using an endorectal technique similar to Hirschsprung surgery, as long as it is backed up with an ileostomy.
A 3-year-old with severe ulcerative colitis (one of the youngest cases seen) had rectum that felt like tissue paper but was successfully treated with endorectal pull-through and J-pouch, with the child blossoming afterward.
Continued bleeding from the rectal stump after subtotal colectomy can force earlier-than-anticipated completion of pull-through, occurring more frequently than realized.
One problem with three-stage ulcerative colitis surgery is that patients often gain 20-30 pounds between stage 1 and 2, making the subsequent operation harder.
Double-staple technique for ileal pouch-anal anastomosis can be performed by everting the rectum and stapling at the top of the columns, requiring a 21mm stapler.
If a patient has received infliximab within the last 6 weeks, there is evidence (both adult and pediatric) that a three-stage procedure should probably be performed due to increased complication risk.
CT enterography may be more accurate than MR enterography according to a recent review study, though institutional radiologist expertise determines which modality performs better locally.
Contrast-enhanced ultrasound in Europe has sensitivity and specificity as high as 100% for Crohn's disease in previously undiagnosed patients, and above 95% in those with known diagnosis, according to a 2013 Peloda study in Pediatrics.
Peristomal complications are unique to Crohn's patients, including fistulas around the stoma.
Crohn's disease affects the entire GI tract, though one particular segment may be strictured at a given time.
Current adult literature recommendations for perianal Crohn's include non-cutting setons, with Remicade exposure ranging from 25-100% of patients.
Endorectal advancement flap results for perianal fistulas diminish with time.
Even with permanent diversion, as high as 40% of Crohn's patients have recalcitrant perianal disease as they reach adulthood.
A study of approximately 120-130 straight ileal-anal anastomoses and 110-115 J-pouches (10 cm pouches) showed hardly any difference in bowel frequency at 2 years.