Natural Ways to Treat Crohns Disease

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Endoscopic Diagnosis of Crohns Disease

Endoscopy plays a major role in the diagnosis of Crohn's disease, especially with colonoscopy and ileoscopy however, upper gastrointestinal endoscopy, enteroscopy, capsule endoscopy and endoscopic ultrasound (EUS) may help confirm and determine the extent of disease. Direct visualisation of mucosal lesions and the possibility of obtaining histologic specimens make endoscopic procedures the first-line tests in the evaluation of gastrointestinal diseases. However, radiology and magnetic resonance imaging (MRI) contribute to the diagnosis when visualising the small bowel 1 .

Endoscopic Features of Crohns Disease

Morphologic pictures observed during an endoscopic procedure are protean. The earliest endoscopic finding is the aphthous ulcer with a diameter of a few millimeters surrounded by a thin red halo of oede-matous tissue 2 , which is found in about 30-40 of patients with Crohn's colitis. Focal oedema and sporadic red spots are present in the preaphthoid phase 3 . These lesions usually are multiple, becoming stellate or linear in shape, with normal intervening mucosa, and can be rounded or long and serpigi-nous. Cobblestone-like areas are formed when ulcers assume a longitudinal and transverse pattern forming a grid. This is due to submucosal oedema, including nonulcerated mucosa 4 . Sometimes, these lesions differ little from inflammatory polyps or pseudopolyps also often present in Crohn's colitis 5 . The presence of punched-out ulcers adjacent to inflamed mucosa gives rise after healing to mucosal bridges. Stenosis is often present in areas of severe inflammation, especially in the...

Nutritional Care in Children with Crohns Disease

Between 15 to 40 of children with Crohn's disease suffer from malnutrition and growth failure, puberty retardation and development of secondary sexual characteristics retardation 4 . The slowing down of height velocity has been also observed 4, 5 . What is clinically relevant is that malnutrition may affect as many as 25 of children even before the apparent onset of the disease 5 . Some factors are involved such as the catabolic state during the acute and or persistent active phase, anorexia leading to insufficient calorie intake to cater to the subject's needs during the critical growth phase, malabsorption and protein dispersion, and deficiencies of zinc, calcium, magnesium and phosphorus. Moreover, steroid treatment plays its most detrimental role in children. A number of hormone deficiencies have been considered such as GH, thyroid hormones and cortisol. A significant correlation between height and body-weight deficits and low circulatory levels of IGF-I has been found 6 , which...

Elective Procedures in Crohns Disease of the Colon

Elective surgical strategy for Crohn's disease of the colon is somehow different from the strategy for CD of the small intestine. Due to the role of the small intestine, surgical procedures must aim to minimise the risk of short bowel syndrome. The large bowel is mainly responsible for the fluid-electrolyte balance. Surgical procedure performed in colonic Crohn's disease should minimise the risk of recurrence and also improve the quality of the patient's life 22 . Symptoms of colonic Crohn's disease depend on the location and extensiveness of pathological changes. Right colon and ileocecal involvement with concomitant obstruction require surgery in 90 of cases. Crohn's disease affecting the left colon requires surgical procedure in 60 of patients, and usually occurs in older patients. However, only 30 of patients with rectal CD require operation. More than a half of the patients with Crohn's disease located in the left colon and rectum will require a stoma, but their quality of life...

Perianal and Colonic Crohns Disease

When isolated perianal Crohn's disease is present, loop ileostomy is often offered to patients as a temporary or definitive solution. Laparoscopic ileostomy construction is easily performed 20 and at the same time it gives the possibility of performing a complete abdominal exploration in order to detect additional sites of disease. Bowel obstruction due to bowel twisting is a possible complication and therefore particular care has to be taken to mark the bowel in order to exteriorise it in the proper manner and with the proper orientation. As a general rule, during surgery for Crohn's disease, all the scars and all the port sites must be positioned in areas distant from possible sites that may have to be used in the future for stoma creation.

Do Patients with Crohns Disease Differ Psychologically from Those with Ulcerative Colitis

According to German authors, the psychological pattern of patients with ulcerative colitis is more uniform, older patients with Crohn's disease appeared more depressed whereas younger individuals look more active but have pronounced dependency conflicts 20 . North and Alpers reported that Crohn's disease, unlike ulcerative colitis, may be statistically associated with lifetime psychiatric disorders 21 whereas Porcelli et al. found no significant difference as far the capacity to express emotions between ulcerative colitis and Crohn's disease patients 22 . The same finding, i.e. no significant differences among the two types of IBD, was reported by others when looking at the of state anxiety and depression even if both Crohn's disease and ulcerative colitis patients looked more anxious and depressed than controls 23 . The degree of correlation between psychosocial stress and subsequent increased disease was found to be higher in patients with Crohn's disease than in those with...

Depression How Crohns Disease Patients Defend Themselves

Depression itself is a mechanism of defence in a person whose quality of life is severely affected by Crohn's colitis. The more the patient interacts with people, deals with his her job, enjoys - or tries to enjoy - social life, the more he she gets frustrated and suffers, as routine daily activities are prevented by anal soiling, frequent diarrhoea or abdominal pain Therefore, depression, i.e. refusal to participate actively in life, introversion and self-confinement to a comfortable jail represented by his her own dark bedroom, may represent an apparent provisional solution to feel safe and to avoid further conflicts, at least with the external environment. This is especially true for patients classified as very poor or grade 4 in Helzer's and coworkers' grading scale of Crohn's activity index 28 . Instead of being criticised for clearly manifesting fear of people and work, the patient prefers to create a personal, inviolable safe shell, i.e. to be depressed. After all,

Crohns Disease A Failure of Mucosal Immunoregulation

Implicit in the function of the mucosal immune system is the ability to mount an immune response to pathogens whilst maintaining tolerance to the vast array of luminal antigens derived from food and commensal bacteria. The fact that many animal models of Crohn's disease remain disease-free if reared in germ free conditions suggest that luminal bacteria are involved in either the initiation or prolongation of intestinal inflammation. Further evidence for this hypothesis is provided by clinical studies showing that diversion of the faecal stream from an area of active inflammation via a defunctioning split ileostomy induces remission in 65-70 of patients with Crohn's disease, the majority of whom will relapse after the reintroduction of ileal effluent.21,22 A lack of tolerance to intestinal bacteria is probable, as the activity of the ileal effluent is lost after sterilization through a 0.22 m filter. Furthermore, mucosal mononuclear cells isolated from areas of active Crohn's disease...

Systemic IL10 as a Therapy for Crohns Disease

Both the role of IL-10 in the maintenance of mucosal homeostasis and the therapeutic efficacy of systemic IL-10 injections in animal models of colitis indicated its potential as a novel therapy in Crohn's disease.37-39 In vitro studies showed that exogenous IL-10 down-regulates the enhanced pro-inflammatory cytokine release from lamina propria mono-nuclear cells isolated from patients with Crohn's disease.28 Furthermore, in an initial trial of 46 patients with steroid-resistant Crohn's disease, seven daily IL-10 injections induced clinical remission in 50 of patients over the three week follow up compared to only 23 given In contrast, there was no beneficial effect of IL-10 over placebo in a study of the effect IL-10 on post-operative endoscopic recurrence in patients with ileocolonic Crohn's disease.41 Furthermore, two recent studies have investigated the efficacy and safety of 28 daily subcutaneous injections of recombinant IL-10 in patients with moderately active and steroid...

Crohn S Disease Indication To Total Abdominal Colectomy

Except for cancer, the indications for laparoscopic total abdominal colectomy are basically the same as in open surgery. For less experienced laparoscopic surgeons, however, further restrictions may apply such as previous operations with formation of intraabdominal adhesions, obesity, or fistula formation, because these conditions may make laparoscopic orientation and accessibility difficult.1,2 This is especially true for the anatomic regions of the omentum, transverse colon, and meso-colon including its vessels. If the laparoscopic approach proves to be difficult, early conversion is recommended. In Crohn's disease, extensive colonic involvement or pancolitis with rectal sparing is an indication for total abdominal colectomy.3-5 It may also be indicated in rare cases of ulcerative colitis with minimal rectal involvement but still carries the risk of leaving behind the principally diseased rectum with all its consequences.6-10 In familial adenomatous polyposis, the situation is...

Recurrence of Crohns Disease

Crohn's disease is considered to be an autoimmune disorder. Therefore, the possibility of recurrence within the graft is an important issue. So far, only two well-documented cases of recurrent disease have been reported. The first case was a 33-year-old female, who underwent small-bowel transplantation in December 1994. After induction with donor bone marrow infusion and with OKT3, immunosuppres-sion consisted of tacrolimus and methylpred-nisolone. Only 7 months post-transplant did the Table 1. Intestinal transplants for Crohn's disease (Innsbruck experience) Crohn's disease, 14.08.98 Crohn's disease, 10.04.00 Crohn's disease, short-bowel syndrome, renal failure (pyelonephritis) patient develop epithelial granulomas, which is characteristic of Crohn's disease. Resection of a bowel segment became necessary and the graft was eventually removed 17 months after transplantation. Histology revealed recurrent Crohn's disease and no signs of chronic or acute rejection 16 . The second case was...

Surgical Indications in Crohns Disease and Preoperative Preparation

Table 1 summarises indications for surgical treatment in Crohn's disease 4, 12, 13 . Surgery may be either scheduled or urgent. The subdivision into absolute and relative indications is partly arbitrary. Regardless of CD, intestinal perforation is considered to require urgent surgical treatment, but determining

Intestinal Strictures are a Commonly Encountered Problem in Patients with Crohns Disease

Intestinal strictures are a commonly encountered problem in patients with Crohn's disease, resulting in bowel obstruction and eventually in repeated bowel resection and short bowel disease. Over one third of patients with Crohn's disease have a clear stenosing disease phenotype, often in the absence of luminal inflammatory symptoms 39 . At the foundation, as in other organs and tissues, there is transformation and activation of fibroblasts and smooth muscle cells that underlie fibrogenesis in the gut. Endoscopic balloon dilation is the preferred initial therapeutic modality in anastomotic strictures. In fact, endo-scopic management with hydrostatic balloon dilation is an effective alternative to surgery in patients with endoscopically accessible lesions shorter than 7-8 cm 40 , but careful patient selection is of great importance to ensure favourable long-term results. The presence of inflammation near the stricture should not be considered a contraindication to dilation, and...

Crohns Disease Fissure

If a midline fissure appears abnormal or fails to heal with conventional therapy, Crohn's disease should be suspected 26 . Spontaneous healing is observed in 80 of patients with Crohn's fissures followed for 10 years 12 . For this reason, the majority of the fissures may be treated medically. The Lahey Clinic found that only 15 of 56 patients with fissures required surgical treatment, despite 88 presenting with symptoms 27 . A painful fissure is generally associated with an underlying abscess and may require an examination of the patient under general anaesthesia. If an abscess is found, simple drainage as described in the previous paragraph can provide relief without incontinence 25 . If no abscess is found, medical management is appropriate, using local agents such as topical glyceryl nitrate or isosorbide dinitrate, nifedipine or symptomatic measures such as topical steroids or anaesthetic creams. In cases of persistent pain, the fissure may be treated as a classical anal fissure...

Hpv And Crohns Disease

Crohn's disease, a chronic inflammatory condition, may involve the entire alimentary tract from the mouth to the anus. The three major locations of the disease are Perianal or anorectal Crohn's disease affects the patient as a primary feature with a prevalence of 8-90 . Approximately one in three patients are afflicted 2-5 and it is rarely the only site of disease. The prevalence of perianal disease has been found to be greater in blacks than in whites 2 . More than 50 of patients with colon involvement will have anal complications, whereas less than 20 of patients with small-bowel disease will develop anal symptoms 6 .

Clinical Studies on Artificial Nutrition in Crohns Disease

Crohn's disease can be an indication for artificial nutrition, improving patient management and also providing some insights into the nature of the disease, for example with regard to the role of dietary antigens, intestinal permeability and the intestinal inflammatory and immunological response in the pathogenesis and clinical course of the disease. At this point, there is no medical or surgical treatment capable of curing the disease, and the only realistic therapeutic objectives consist of achieving remission of the active phases, treatment of complications, and an attempt to maintain remission with immunosup-pressive agents and more recently with long-term infliximab treatment. Though the obvious aim of artificial nutrition is to improve or restore adequate nutritional status in the presence of malnutrition by artificially administering nitrogen together with an energy source, in Crohn's disease, an increasingly investigated aspect is the assessment of whether or not enteral...

HRQL after RPC in Crohns Disease Patients

IPAA has come to represent the procedure of choice for patients requiring surgery for mucosal UC 36 . In contrast, a proven diagnosis of Crohn's disease is generally held to preclude IPAA. However, patients with IPAA for apparent mucosal UC who are subsequently found to have Crohn's disease have a variable course. In fact, up to 15 of cases of UC are mistakenly diagnosedin patients with Crohn's disease because of overlap in the clinical, endoscopic and histologic findings 52-54 . Even the classic histologic abnormality of Crohn's disease, noncaseating granuloma, is found in only 50-60 of resected specimens 54 . As a result, as many as 3.5-9 of patients who undergo total proctocolectomy and IPAA are found to develop recurrent Crohn's disease in the ileal pouch 55, 56 so that, in retrospect, these individuals presumably had surgery for Crohn's disease involving the colon rather than for UC. In general, patients with Crohn's disease are not usually offered IPAA because recurrence,...

Capsule Endoscopy in Crohns Disease

The diagnosis of Crohn's disease is difficult. Current radiologic and endoscopic studies are limited in the diagnosis of early small-bowel mucosal disease in patients with this disease. VCE detects early lesions in the small bowel of patients with Crohn's disease and is effective in diagnosing patients with suspected Crohn's disease undetected by small-bowel series and enteroclysis 65, 66 and in some cases of Crohn's disease with intestinal strictures missed by enteroclysis. Enteroclysis in patients with Crohn's disease has a diagnostic yield of 37 while capsule endoscopy has a yield of 70 . This is not surprising since enteroclysis will not easily detect flat or mucosal abnormalities 67 . VCE is also superior to CT enteroclysis 5 in patients with known or suspected Crohn's disease, especially in the detection of significantly more inflammatory lesions in the proximal and middle part of the small bowel. VCE probably is less effective than radiology at detecting fistulae, and this...

Crohns Disease

There are very few studies on quality of life issues in Crohn's disease. The issues that impact principally on quality of life are as follows 1. The fear of recurrent Crohn's disease. In Crohn's disease there are often long periods of quiescence between successful surgical treatments. Nevertheless, Crohn's disease is associated with potential life-long disability. Factors which influence recurrence in ileal Crohn's disease are Crohn's disease is associated with a higher risk of losing one's job, early retirement or modification of employment. Patients with Crohn's disease have fewer children, than age and sex-matched normal subjects. Quality of life in Crohn's disease is generally associated with relapse, which compromises work, leisure and social activities 33, 34 . Quality of life is often compromised by growth retardation especially in diffuse disease. The issues we found as having a major impact on quality of life in Crohn's disease were as follows We found that during remission,...

MR Enteroclisis Findings

Early lesions of Crohn's disease such as blunting, flattening, thickening, distortion and straightening of the valvulae conniventes and tiny aphthae were clearly shown at conventional enteroclysis, but they were not consistently depicted with MR enteroclysis due to its inadequate spatial resolution. The valvulae conniventes were shown to their best advantage and distortion of the mucosal folds was easily detected with MR enteroclysis. The characteristic discrete longitudinal or transverse ulcers of Crohn's disease could be shown at MR enteroclysis, provided there was satisfactory disten-tion of the bowel. MR enteroclysis was less sensitive than conventional enteroclysis in the detection of linear ulcers due to low spatial resolution and lack of compression techniques. Thin high-signal-intensity Fig. 3. A 57-year-old female with active Crohn's disease. a, b Axial fat-suppressed true-FISP images show severe thickening of the terminal ileum with luminal stenosis and fibro-fatty...

Quantification of Dynamic Contrast Enhanced Mri Dce

Clinical scoring (such as the Crohn's disease activity index 32 , biologic indexes 33 , endoscopy, and imaging studies have all been used to monitor activity, but no established gold standard exists. Assessment of activity is usually made using a combination of clinical symptoms, physical findings, laboratory investigations, endoscopy, and imaging tests. The assessment of biologic activity, based on the positiv-ity for three of four acute phase reactants (WBC, ery-throcyte sedimentation rate, and C-reactive protein), has been found to be a sensitive determinant of activity, especially when supported by endoscopic or imaging findings.

Descriptie Epidemiology

Inflammatory bowel diseases (IBD) are a collection of diseases affecting the bowel, the most common of which are ulcerative colitis and Crohn's disease. Whereas UC is characterised by a continuous distribution of mucosal submucosal inflammation within the colon, CD may result in focal areas of disease in any part of the gastrointestinal tract from the mouth to the anus the inflammation is transmural and almost inevitably progresses over time, often leading to structuring or fistulising complications. Extraintestinal complications affecting eyes, skin and joints occur in both illnesses. Although inflammatory bowel disease is not common or highly fatal, it is important to public health because its highest incidence is early in life, its therapy involves major surgery including a curative colectomy for ulcerative colitis, and having the disease increases the risk of developing colon cancer. There are literally hundreds of articles describing the incidence of ulcerative colitis and...

Recommended Approach to Diagnosis

Ulcerative colitis and Crohn's disease have, in many cases, quite distinguishing histopathological features with typical investigative findings and clinical features however, this is not universal and in many cases these features might overlap. Common histological changes might be absent or the changes may lack the characteristic features, therefore the findings usually need to be analysed more meticulously in the all-important clinical pathological conferences (CPCs). Despite all the efforts, there are cases where it is not possible to give a definite diagnosis and which might need further investigation 25, 26-29 .

Screening and Treatment Options of Patients with Dysplasia Associated IBD

The evidence of the association of dysplasia with cancer in patients with IBD has been noticed since the first publication of Crohn and Rosenberg early in the 1900s 41-43 . The fact that dysplasia is commonly seen near areas of invasive carcinoma in up to 74 of resection specimens from IBD patients, has lead to the conclusion that this is a precursor to the invasive lesion 44 . The diagnosis of dysplasia in patients with IBD is a crucial step because in some centres it will leave the patient with either a colecto-my or life-long surveillance to prevent the development of cancer 25 .

Human In Vitro Studies

Sion is decreased in the inflamed and non-inflamed colon of CD, while that is not the case in UC 64 . The cell types involved in the altered motor pattern include interstitial cells of Cajal 65 , which are damaged and presumably contribute to altered motility. In tissues from Crohn's disease patients, the density of interstitial cells of Cajal is reduced throughout the tunica muscularis, suggesting that the disturbance of intestinal motility that occurs in patients with CD may be a consequence of the loss of or defects in specific populations of interstitial cells of Cajal within the tunica muscularis 66 . Hypersensitivity to cholinergic stimulation has been demonstrated in the colonic smooth muscle from patients with UC and it may result from increased calcium release from intracellular stores 67 .

Animal in Vivo and in Vitro Studies

As already described, the mechanisms of altered motility in IBD are unclear but may reflect changes in the axon smooth muscle cell relationship and data suggest that the enteric nervous system (ENS) has an important role in the motility defects 68 . A limitation in understanding the etiology of IBD is that few animals spontaneously develop colitis and several animal models, particularly the hapten 2,4,6-trini-trobenzenesulfonic acid (TNBS) in ethanol have been used to produce an acute inflammation that progresses over several weeks to a chronic stage that is morphologically similar to Crohn's disease. Data in animal models are controversial. Measurements of In Vivo motility patterns in dogs during acetic acid-induced ileitis showed that inflammation increased the frequency of giant migrating contractions and decreased the frequency of migrating motor complexes and tone 69, 70 . A study evaluating colonic motor response to a meal in acute colitis dogs showed an absence of motor...

Upper and Small Bowel Endoscopy

Esophagus, stomach and duodenum may be involved by Crohn's disease 23 . Even in the upper gastrointestinal tract, aphthous ulcer is the most common lesion, but mucosal nodularity and stenosis may be seen 24 . The presence of inflamed mucosa in this portion of the digestive tract is important for differential diagnosis between Crohn's disease and UC. Radiologic procedures with barium as small-bowel follow-through or enteroclysis are important for diagnosis of Crohn's disease localised in the small bowel and for demonstration of strictures and fistu-lae 25 . However, a study comparing small-bowel barium examination with enteroclysis and ileoscopy showed that the radiology missed 27 of severe inflammatory changes and 50 of mild inflammatory changes 26 . Push enteroscopy allows evaluation of the proximal small bowel whereas intraoperative enteroscopy is used to explore the distal small intestine 27 . The former procedure is useful especially in patients without known Crohn's disease but...

Endoscopic Retrograde Cholangiopancreatography

Primary sclerosing cholangitis is a complication of IBD, present especially in patients affected by UC with an incidence between 1 and 4 and with lower frequency in Crohn's disease 32 . Patients with IBD and abnormal liver function test need to be evaluated for hepatobiliary complications. Depending on local availability, MR cholangiography or endoscop-ic retrograde cholangiopancreatography should be performed as the initial diagnostic test in the suspicion of sclerosing cholangitis. The latter procedure is indicated as the procedure of choice when biliary stenosis is suspected or evident.

Endoscopic Ultrasound

EUS is a procedure for imaging the intestinal wall at high resolution. The use of EUS shows findings that distinguish normal colon from IBD as increased wall thickness, lymphadenopathy or enlarged perirectal vessels 33 . In particular, vessel enlargement is more likely associated with patients with acute Crohn's disease whereas adenopathy is associated with acute UC. Therefore, this procedure could be helpful in differentiating the two diseases. An alternative to EUS is the high-frequency ultrasound catheter probe. In one study, a 20-MHz radial catheter was used to evaluate the colorectal wall in patients with IBD 34 . Crohn's disease was associated with thickening of the fourth hypoechoic layer (muscularis propria) or loss of layer structure, and mucosal and submucosal thickening was more likely in ulcerative disease. Moreover, EUS plays a major role in diagnosis and assessment of Crohn's anorectal and perineal complications, such as abscesses or fistulae. Barium fistu-lography and...

Intraluminal Contrast Media

Adequate distension of the bowel lumen is mandatory in MRI, as it facilitates demonstration of morphological changes caused by Crohn's disease and allows identification of subtle abnormalities. Collapsed bowel loops can hide lesions or mimic disease by mimicking pathologically thickened bowel wall in

Spectrum of Inflammatory Bowel Disease

The spectrum of inflammatory bowel disease results in major differences with respect to quality of life among patients with ulcerative colitis compared to those with Crohn's disease. In ulcerative colitis, only the colon and rectum is involved, the sphincters are spared and there is no small-bowel involvement. Although many of these patients present with acute fulminating colitis requiring an emergency colecto-my, a high proportion of these patients can today be reassured that the stoma might be temporary and that there is an 80-95 chance of full continence, albeit with some diarrhoea after colorectal excision and pouch construction. There is of course a risk of malignancy and there is the risk that conventional surgery may be associated with complications resulting in a permanent stoma. At the other end of the spectrum is Crohn's disease, which may affect any part of the gastrointestinal tract. The anal sphincters are commonly affected. There is a high risk of incontinence and...

Nephrotoxicity from Medical Treatment

Left-side ureteral obstruction secondary to Crohn's colitis. a Preoperative intravenous pyelography showing a dilated ureter with smooth cone-shaped restriction at the pelvic brim. b Intraoperative identification of the ureter after mobilization of descending and sigmoid colon. c iv pyelogram 6 months after resection of the affected bowel demonstrating a resolution of ureteral obstruction

Efficacy on Remission and Maintenance Therapy

Bblogical therapy in Crohn's disease Induction therapy is effective in up to 70 of cases 10, 12, 17-30 . Nt responders to induction therapy do not respond to a maintenance therapy. In patients who respond to induction therapy, maintenance therapy may prolong complete clinical remission Crohn's Disease Activity Index (CDAI) < 150 after 1 year in about 40 of cases, with clinical response in 60 of cases. This implies that, after 1 year of prolonged infliximab therapy, only 25 of patients attain complete clinical remission and 35 clinical response 10, 12, 17-29 . There is evidence that an increase of infliximab dosage and or a reduction of interval time between infusions may main

Mercaptopurine and Azathioprine

2-3 mg kg day and 6-MP at a dose of 1.5 mg kg day are effective for the treatment of CD. Although titration of either drug to a specified blood 6-thioguanine nucleotide metabolite concentration (6-thioguanine > 235 pM 108 erytrocytes) has been suggested for improving therapeutic efficacy, this has not been demonstrated convincingly in the treatment of Crohn's fistulae 28 .

The Future Will Genetics Indicate the Appropriate Therapy

As already described, CD manifestations may be subdivided into two main categories penetrating Crohn's disease and non-penetrating or fibrostenotic Crohn's disease 23 . This subdivision, now formalised, was known and reported in many works 59 , even if it was not univocally accepted 60 . What is interesting is that the manifestations of the disease tend not to change, even in the case of postsurgical relapse.

Indications for Surgery

Despite the fact that colectomy with ileostomy is the most frequently performed type of procedure, restorative proctocolectomy finds increasingly more advocates. In a selected group of patients with no changes in the rectum, this type of surgery offers the chance of avoiding intestinal diversion. In severe stages of Crohn's disease, the risk of performing restorative proctocolectomy is very high with a complication rate reaching 56 of patients. Fisher et al. 22 reported that 64 of patients who have undergone restorative proctocolectomy had complications of a fistula, pouch stenosis and or pelvic abscess. The same complications occurred only in 22 of patients with ulcerative colitis treated with this surgical modality. Pouch failure was reported in 56 of Crohn's disease patients, and was dramatically lower in a group of patients with ulcerative colitis, reaching only 6 . The major goal of the ileo-rectal anastomosis is to preserve the continuity of the physiological tract but may not...

Restorative Proctocolectomy

Proctocolectomy with pouch is possible in selected group of patients with Crohn's disease. It is not appropriate to perform in cases of rectal, anal and small intestinal disease. If above excluding criteria are respected, it is possible to achieve satisfactory long-term results. It has to be remembered that complications may lead to the necessity of pouch excision and diversion. Mylonakis 29 reported that during 10.2 years of follow-up, 47 of patients experienced complications leading to the excision of the pouch. There is also a report of only 19 of complications in a selected group of patients with no pathological changes in rectum, and in distant part of ileum 30 . Despite that fact, restorative proctocolectomy is not a preferred type of surgery in patients with Crohn's disease.

Segmental Resection of the Large Bowel

In some patients with Crohn's disease of the large bowel limited to isolated segments, a partial resection of the colon may be a reasonable solution. This method maintains the macroscopically unchanged segments of the colon and their activity regarding fluid-electrolyte balance, and also decreases the risk of episodes of gas and faecal incontinence in contrast to patients after colectomy with anastomosis. Following resection, the number of stools is approximately 2 per day, and the number of stools following colectomy with ileo-rectal anastomosis are 5 per day 32 . Segmental resection is a surgical procedure that can be allowed only in certain, selected groups of patients. Partial resection of the large bowel has a therapeutic value (low recurrence) in patients with the changes in the large bowel not exceeding 20 cm of bowel length. Patients avoid diversion, but unfortunately a risk of reoperation still exists. The risk of another resection involves 25-72 of patients. Longo et al. 33...

How Much Bowel to Resect

Unlike in large-bowel involvement, in the case of Crohn's disease affecting the small intestine, surgical procedure is standardised. The role of surgery in CD is limited to the treatment of complications which do not respond to conservative therapy. In contrast to ulcerative colitis, CD is incurable. The high percentage of recurrences after surgery in this group is the reason for limitations in surgical procedures. The percentage of recurrences is estimated to be 55 during the 15-year period after the first surgical procedure 27 . Short-bowel syndrome is one of the most serious complications after surgery of CD with the localisation in the small intestine. Multiple laparotomies and intestinal resections result in a decrease of the total length of the small intestine. When the length of the intestine falls below 2 m, serious clinical problems appear. The introduction of new operating techniques strictureplasty has limited this complication considerably 34 . The strategy of surgical...

Toxic Fulminant Colitis

Toxic colitis is a severe, life threatening complication manifested as a sudden, and deteriorating clinical condition, bloody diarrhoea, peristaltic abdominal pain, development of toxaemia, emaciation and high fever. Previously believed to be more common in the case of ulcerative colitis, it is now currently proven, based on conducted studies, to be the case in up to 50 of Crohn's disease. When toxic colitis is accompanied by a dilatation of the large intestine, toxic megacolon develops. Fibrosis and stenosis of intestinal walls in Crohn's disease may result in an X-ray without intestinal dilatation that is so characteristic for toxic megacolon. Treatment of toxic colitis should be carried out in an intensive care unit and include aggressive fluid transfusions, intravenous

Postoperative Recurrence

The most pertinent clinical outcome in the postoperative period is the requirement for reoperation. The need for surgical reintervention follows a similar prevalence relating to the site of disease and mirrors that for the first operation. Thus, ileocolic disease at 53 is generally associated with higher rates of reoperation than isolated colonic (45 ) or small bowel disease (44 ) 10 . In the National Cooperative Crohn's Disease Study, more than 70 of patients who underwent resection for ileocolitis required a second intervention within 15 years, and the median time to reoperation was between 5 and 10 years 6 . Stric-turing jejunoileal disease is much less common but is recognized as having the highest relapse rates 13,14

Clinical Presentation

Most patients with Crohn's disease present with weight loss, abdominal pain and diarrhoea. An isolated anal lesion is the first manifestation in 5 of patients. Most will develop intestinal symptoms, sometimes many years later 1 . The spectrum of anal complaints is great. Fissures and oedematous skin tags are most common. In the general population most anal fissures are located in the posterior midline. In patients with Crohn's disease, fissures may occur eccentrically. They are deep, indolent and rarely painful unless an abscess is present. Skin tags are usually asymptomatic, but if they become painful or interfere with anal hygiene, they can be excised. They also are an excellent source for biopsy specimens for the presence of granulomata. Other common clinical manifestations include anal stricture, ulceration, complex fistulae, abscesses and finally faecal incontinence. Haemorrhoids are not a common feature of anal Crohn's disease. Management of these varied clinical manifestations...

Sanitising the Perineum

Abscesses must be drained and necrotic tissues excised. Any granulation tissue should be curetted, and sinuses must be deroofed. Simple fistulae should be laid open, more complex fistulae should be drained and the primary track marked by a loose seton. The intention is to end up with a healthy surgical wound from which to use as a starting point. Medical treatments are discussed in a previous chapter and are always considered as the first choice in perineal Crohn's disease treatment. In cases of failure or recurrence, new procedures such as local injection of antibody tumour necrotising factor (TNF) or glue sealing treatment are the second option in fistulae treatment. Finally, if none of these therapies are suc cessful, then quite complicated surgical procedures can be attempted with a reasonable chance of healing. All these procedures and the results will be discussed the sequence is summarised in an algorithm for treatment of perineal Crohn's disease.

Local Injection of Antibody Tumour Necrotising Factor TNF

The TNF blocker infliximab has been proven to be safe and effective in the treatment of both luminal and fistulising Crohn's disease, particularly when used as maintenance therapy with infusions at fixed intervals 50, 51 . This treatment is described in the medical treatment chapter. Further advantages of infliximab therapy include the steroid-sparing effect, the decrease in concomitant anti-inflammatory medication use (mesalazine, sulfadiazine), as well as the reduction in hospitalisations and surgeries and the improved quality of life. Some recent pilot studies have reported the potential benefit of local injection of infliximab for the treatment of perianal fistulae in Crohn's disease 52-54 . It seems that this method of administration minimises the adverse effects associated with the systemic use of infliximab 55 . These injections are repeated every 4 weeks until complete remission is reached and maintained. Lichtiger reported nine patients with mild to moderate perianal disease...

Glue Sealing Treatment

More recently, fibrin glue injection has also been proposed as an alternative to classical methods of surgical treatment for obtaining long-term healing of Crohn's anal fistulae 56 . The use of fibrin glues in the treatment of fistulae-in-ano has been described over the last 12 years. The results published on this subject report success rates of up to 85 (Table 2) 57, 63 . The series studied in the literature so far have included only a very small number of patients suffering from inflammatory diseases where this type of treatment gives rather poor success rates 58,60-63 . Several authors have therefore concluded that the existence of a fistula complicating CD is a predictive factor for failure of fibrin glue injection treatment. Vitton et al. included only CD patients with anoperineal fistula tracts in an original study 56 . After a long follow-up period of nearly 2 years, their report shows that more than half (57 ) of the 14 patients treated with this method were still...

Differential Diagnosis

Fistulae and perianal abscesses should be suspected as being the expression of misdiagnosed Crohn's disease. Review of the proctocolectomy specimen and new biopsy samples are needed to make a correct diagnosis. If Crohn's disease is suspected, a small-bowel follow-through x-ray will rule out disease above the pouch. Approximately 5 of IPAA surgery is performed in patients whose primary diagnosis of UC is revised at some point after surgery to a definitive diagnosis of Crohn's disease. Other disorders that are able to mimic pouchitis symptoms are bile acid malabsorption, irritable pouch syndrome 31 , and chronic pelvic sepsis.

IntroductionTo Cut is not to Cure

The challenge of inflammatory bowel disease (IBD) is formidable. For the patient, there are the symptoms of the disease, causing personal suffering and interference with physical and social activities. For the clinician, the problems are just as challenging the patho-genesis is yet obscure, and the diagnosis, especially for Crohn's disease, can prove frustrating, as the disease may be diffuse and latent in parts of the bowel that appears normal. The surgeon can be particularly frustrated by the knowledge that he or she can never claim to be able to cure the patient's problem. The crude recurrence rate of Crohn's disease was 72 1 year after surgery and 77 after more than 3 years in a large series of 114 patients reported by Rut-geerts et al. 1 . Unfortunately, there was a progressively more severe nature of the lesion at the longer follow-up intervals. Optimal therapy has been reported to embrace many possibilities drugs, nutrition, psychology and surgery 1 , but surgeons, due both to...

What the Surgeon Should Really Know

- NO, it is unlikely that emotional distress causes IBD (the father with the penile foot might not himself have caused ulcerative colitis by abusing his son), but a significant proportion of Crohn's patients have psychiatric disturbances before the onset of their disease. On the other hand, IBD frequently causes major psychological disorders in the first year of the disease. - YES, depression is more likely to affect a patient with Crohn's disease rather than a patient with another medical disease. Patients with Crohn's disease, unlike those with ulcerative colitis, have lifetime psychiatric disorders, and stress may influence their recurrence rate.

Prevention of Post Operative Relapse

The 5-aminosalicylates remain the most controversial agents in the maintenance of remission of Crohn's disease. Several studies and a recent meta-analysis have shown no significant benefit in comparison to placebo, but the meta-analysis suggested a potential role in patients with surgically induced remission, where mesalazine lowered the risk of relapse by 13 26 . These general data were better clarified in a randomised study in which 5-ASA gained a significant reduction in relapse rate in postoperative prophylaxis in a subgroup of patients with limited ileal disease 27 . Therefore, while waiting for confirmation data, our team routinely treats resected patients for ileal CD.

Management Outcome and Complications

The incidence of pouchitis has been reported to range between 4 and 40 in patients with a Kock reservoir for ulcerative colitis 25, 26 . The diagnosis is based on the typical above-mentioned symptoms and on an endoscopic biopsy that reveals diffuse bleeding inflammation and or a villous atrophy. However, the histological features are often non-specific and may hide Crohn's disease. It is likely that this pouchitis rate is higher in patients who underwent the same operation for Crohn's disease than in those with ulcerative colitis, and much lower in patients operated on for familial adenomatous polyposis besides, the more the follow-up lengthens, the more the incidence of pouchitis increases. In 1993,

Perianal Abscesses and Fistulae

Many of them underwent more than one operation for fistulae. When cases of Crohn's disease are described as fis-tulising, one has to distinguish between perianal and intestinal fistulation. The question, however, remains open as to whether or not there is truly an association between perianal fistulisation and intraabdominal intestinal fistulisation in CD. There is a statistically significant association between perianal CD and intestinal fistulisation, which is much stronger and more consistent in cases of Crohn's colitis than in cases limited to the small bowel 3 . The management of perianal CD continues to be challenging. Roughly half of patients require permanent faecal diversion, which is even more frequently true for patients with colonic CD and anal stenosis. Recognising these tendencies will assist both patients and surgeons in planning optimal treatment 4 . If it is indeed a superficial fistula, the correct course of action for most patients...

Intra Abdominal Abscesses

Intra-abdominal abscesses can be successfully drained by an echoguided mini-invasive access like that described in regards to our patient with ulcera-tive colitis and a subhepatic abscess. In many cases, however, fistula formation and intestinal obstruction is associated with intra-abdominal abscesses, and abscess drainage does not improve the situation in the long term. More than 25 of patients undergoing surgery for Crohn's disease will have either an intraabdominal mass or abscess. Of these masses, 40 will have an associated fistula 19, 20 . Traditionally, the majority of abscesses associated with Crohn's disease have been approached with operative drainage however, improved interventional radiological techniques have resulted in an increased use of percutaneous drainage. Doing so will facilitate an improvement in the patients general condition prior to definitive surgical repair 20 . Non-operative therapy prevented subsequent surgery in half of the patients and may be a reasonable...

Intestinal Obstruction

Intestinal obstruction most commonly occurs in patients with Crohn's disease. Small bowel obstruction is the most common complication requiring surgical correction in Crohn's disease and affects 35-54 of patients 37, 38 . It is important to rule out a malignancy whenever a stricture, especially colonic, is present. The initial management of intestinal obstruction in Crohn's disease is medical therapy. Obstruction that is unresponsive to medical treatment requires resection or possible strictureplasty 39 . Septic problems or phlegmon, a stricture close to a planned resection and extensive ulceration or bleeding are contraindications for strictureplasty. Ileocecal resection is a very satisfactory procedure since most patients enjoy longstanding good health after this procedure. Don't operate until a patient gets a complication from Crohn's disease but don't wait for a complication to become further complicated 40 . Extended resection margins confer no advantage to patients in reducing...

Perforated Cancer in IBD

People with ulcerative colitis and Crohn's disease are at greater risk for colon cancer than the general population. Four patients with bowel perforation because of carcinoma in Crohn's disease are described in the literature 61, 62 . In case of a conservative procedure such as suture of perforated intestine or drainage only or strictureplasty, stenting, biopsies of the perforated area are recommended. Prognosis of carcinoma in IBD, according to Fraschi-ni 61 , is good. His patient underwent a right hemi-colectomy and was alive without recurrence or metastases at the 31-months follow-up. Prognosis of carcinoma in IBD, according to Greenstein 62 , is bad. Two of his patients died because of operative complications. Our patient, who underwent laparo-scopic closure of the cecal perforation, was discharged 6 days postoperatively, but, as mentioned above, he died after a planned right hemicolectomy in his reference hospital.

Conservative Treatment

Spontaneous healing can occur in about half of all patients who still have an unhealed wound 12 months after rectal excision, if the diagnosis is ulcerative colitis almost all persistently discharging wounds will have healed in 18-24 months. Even in Crohn's disease some perineal sinuses can heal spontaneously up to 12 months after proctocolectomy 16 . The patient should be advised and instructed to take an active part in the daily care of the wound. Simple sitz baths are rarely sufficient, and a regular use of a small shower-like Water Pik (Water Pik Technologies Inc., CA, USA) will favour a correct wound cleansing. The dressing should not be too tight to deter mechanical delay of the healing process. Topical antibiotic agents are sometimes useful to alleviate symptoms such as pain, pruritus and local inflammation while systemic antibiotics cannot usually reach therapeutic tissue concentrations 18 and are generally less helpful.

Excision and Primary Closure

Wide excision and primary closure with removal of all fibrous tracks can be a very difficult procedure to carry out, especially in high presacral tracks. Quite often the wound cannot be sutured directly, and resulting the dead space is likely to become infected. As a matter of fact, Scammel and Keighley 24 , in a group of 17 patients with Crohn's disease, obtained primary closure in three cases only. Neoadjuvant RT increases the risk of perineal wound complications after APR 25 . Bullard et al. 26 have recently reported the results of primary perineal closure after APR in a series of 117 patients who received neoadjuvant radiotherapy to downstage rectal cancer and decrease the risk of local recurrence. Major perineal wound complications were reported in 35 . Delayed healing was the most common complication with a mean healing time of 3.8 2.7 months (range 1-12). Five patients developed a PPS four in the RT group, one in the control group. The authors concluded that in patients...

Cutaneous and Myocutaneous Flaps

Many techniques of muscle transposition have been described for the treatment of PPS. The procedure can be carried out soon after the excision of the sinus, usually involving parts of the coccyx and lower sacrum, or a few days later, when the walls of the cavity are covered with granulation tissue 16 . Marti et al. 27 used a wide V-Y full-thickness flap to cover large perineal defects in six cases (Fig. 1). The authors used this technique in two cases of giant condyloma of the perineum without the involvement of the anal canal, two cases of hidradenitis suppura-tiva and two cases of salvage total rectal excision after failed radiotherapy for anal carcinoma. All wounds healed primarily without infection even in the last two patients who, as reported, had signs of perineal radiodermitis. In persistent perineal sinus after proctectomy for Crohn's disease, Bascom et al. 28 suggest an easy technique, using a skin flap 1 cm thick, whose healing is favoured when an asymmetric suture line is...

Surgery for IBD and FAP

Among the existing colic surgery protocols, one that certainly deserves to be mentioned is the protocol developed by Kehlet and his Danish team 2 with their concept of accelerated rehabilitation, they developed a series of perioperative treatments that allow speedy recovery and an early dismissal. This treatment concept preserves bodily organ functions and avoids the usual postoperative deterioration in pulmonary function, body composition and cardiovascular response to exercise 3 . (See Table 1 for a comparison of this protocol with the Conventional Care and Multimodal Rehabilitation programmes.) The multimodal rehabilitation programme, with epidural analgesia, early oral nutrition and mobilisation, besides application after open colonic surgery for noninflammatory bowel disease, is also used after ileocolic resections for Crohn's disease 4 . Andersen and Kehlet, at the end of this prospective, nonrandomized study, observed that open ileocolic resections for Crohn's disease combined...

Entero Urinary Fistula EUF

Entero Vaginal Fistula

The majority of fistulas result from direct contact between inflamed terminal ileum and the bladder dome (ileovesical fistula). Sometimes an intervening abscess is present and in this case it is not unusual to find more than one intestinal segment involved in the fistula 63, 64 . Crohn's colitis, and more rarely UC, can determine a colovesical fistula which generally involves the sigmoid colon 59 . Severe rectal disease can cause rectourethral fistulas, but this is a rare event. Other unusual fistulas are those between the terminal ileum and ureter, or urachus. Table 4. Presenting symptoms in 78 Crohn's disease patients with entero-urinary fistulas. (Adapted from Solem et al. 65 ) Table 4. Presenting symptoms in 78 Crohn's disease patients with entero-urinary fistulas. (Adapted from Solem et al. 65 )

Operative Technique

Ileal Pouch Construction

The operation is usually performed with the patient in the Lloyd-Davies position. With the surgeon standing to the patient's left side, the abdomen is entered through a midline incision and fully explored, with particular attention paid to any signs of small-bowel Crohn's disease. Extreme care must be taken when handling the friable bowel in order to avoid colonic traction and to provide easy exposure of the colonic flexure. The entire colon is mobilised away from any retroperitoneal attachments, starting from the cecum (Fig. 3). To avoid injuries, the right spermatic vessels and the right ureter are identified through their course.

Rectus Abdominis Myocutaneous Flap

Gracilis Myocutaneous Flaps

This technique was described by Taylor et al. in 1983 35 . It is an excellent method for closing a large perineal defect. Based on the inferior epigastric artery and vein, it may be passed into the pelvis to close the pelvic floor and fill the dead space. It is best employed pro-phylactically in high risk patients at the time of proc-tectomy when potential perineal wound problems are anticipated 17 , or at the time of abdominoperineal excision for a large neoplasm 34 when extensive perineal excision is needed in Crohn's disease 36 , or, finally, when the combined approach is used to excise a large perineal sinus in Crohn's disease or after radiotherapy 16 . As a delayed or secondary procedure, the advantages of this flap must be weighed against the potential difficulties and morbidity of having to reenter the lower abdomen and mobilise the bowel to provide space to pass this flap into the pelvis, which is often severely fibrotic. Moreover, in very large pelvic wounds, the bulk of a...

Treatment of Anorectal Suppuration

To treat anorectal abscesses, some guidelines must be followed. Spontaneous healing and complete resolution of perianal cellulitis is very rare and should not be expected. Broad-spectrum antibiotics without drainage delay the need for surgery and create more complex lesions. Microbiological investigations may be useful for obtaining evidence of some specific infection or of an anal venereal disease. Incision should not be delayed and should allow optimal drainage without pocketing. A lay-open or one-stage operation should not be performed in cases of Crohn's disease.

Extra Mural Manifestations and Complications

MR enteroclysis had a clear advantage over conventional enteroclysis in the demonstration of extramural manifestations or complications of Crohn's disease. The extent of fibro-fatty proliferation and its composition, mostly fatty or mostly fibrotic, could be assessed with MR enteroclysis, especially when true FISP images were obtained (Fig. 3). The so-called

Rectovaginal Fistulae

Rectal Mucosal Flap Surgery

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 anorectum. This type of fistula carries a poor prognosis 79 . Patients with rectovaginal

Recto Vaginal Fistula

Fistula Perianal

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 . Table 1. Efficacy of standard medical and of routine surgical treatments in different types of Crohn's disease fistulae, and the percent of patients requiring more complex surgical intervention 5 Table 2. Parameters used for the evaluation of fistula-specific activity index in Crohn's disease Table 2. Parameters used for the evaluation of fistula-specific activity index in Crohn's disease

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 inflamed specimen to be removed. Due to the friability of the inflamed tissue, care has to be taken in order to avoid bleeding during the extraction manoeuvres of the thickened mesentery and the mesentery has to be divided outside the abdominal cavity 6,8,13 . On the other hand, severe disease with large inflammatory masses is cause for conversion to open surgery in up to 40 of cases, Reduced stay Reduced cost Laparoscopy feasible in fistulous Crohn's Exclusion for previous resections for Crohn's

Hull T.l.1996 Work On Ileostomy

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 abscesses in symptomatic perianal Crohn's. Int J Colorectal Dis 11 222-224 5. Williamson PR, Hellinger MD, Larach SW et al (1995) Twenty-year review of the surgical management of perianal Crohn's disease. Dis Colon Rectum 38 389-391 6. Williams DR, Collier JA, Corman ML et al (1981) Anal complications in Crohn's disease. Dis CoIon Rectum 24 22-24 7. Allan A, Keighley MR (1988) Management of perianal Crohn's disease. World J Surg 12 198-201 9. Borley NR, Mortensen NJ, Jewell DP (1999) MRI...

Anal Skin Tags and Haemorrhoids

Skin Tags After Hemorrhoids

Haemorrhoids are uncommon in patients with Crohn's disease. They usually become symptomatic when accompanied by diarrhoea. Conservative treatment must include control of bowel function, warm sitz-baths, and topical medications. Usually these non-invasive measures are successful. If symptoms persist, rubber-band ligation might be helpful. In rare cases, if symptoms are severe, and the rectum is spared from illness, selective surgical haemor-rhoidectomy may be successful 28 . Most surgeons believe that surgery should be avoided in the treatment of haemorrhoid diseases in Crohn's patients. In a publication, Jeffery et al 31 reported the results of 21 patients with Crohn's disease presenting with active haemorrhoids that were treated surgically. Postsurgical complications, including sepsis, strictures, fistulae and unhealed wounds, occurred in ten patients, and six patients ultimately required a proctectomy.

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 therefore not recommended.

Microscopic Features of IBD

From the crypts in a biopsy showing features of chronicity are a strong indicator of a diagnosis of Crohn's disease 63 . The mucosa sometimes contains dilated blood vessels some of which may contain thrombi 64 . Features of endarteritis obliterans are seen in submucosal vessels and the muscularis mucosa may appear reduplicated 65 . In quiescent disease the mucosa may appear nearly normal with slight crypt distortion and presence of Paneth cells and very occasional neutrophils in the lamina propria 66 . As mentioned earlier, if the rectal biopsy appears normal, a diagnosis of UC is unlikely. However, subtle inflammatory changes can occur, especially if the patient is a child or if the disease has been treated with steroids 67, 68 .

One or Two Stage 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 for months or years. The prevalence of abscesses in patients with perianal Crohn's disease is approximately 50 5, 22, 23 . The cause of Crohn's abscesses (Fig. 3) is not completely understood. Following Park's theory, which states that an infection begins in the anal gland in the intersphincteric space and all other tracts and collections are secondary 24, 25 , many investigators believe that Crohn's abscesses are no different than crypto glandular abscesses. Other investigators believe that...

Cause or Just Association Psychiatric Illness and IBD

Some confusion has occurred in the past decades on the psychosomatic aetiology or pathogenesis of IBD. There is enough evidence that depression or any psychiatric diagnosis is statistically more often associated with Crohn's disease than with diabetes, hyper tension or cardiac diseases 29 and that emotional distress may cause exacerbation of IBD, as reported at the beginning of this chapter with the sad story of Angela F. Psychiatric illness may precede the onset of Crohn's disease, but no significant data have been reported to strongly support a causative relationship. Patients with ulcerative colitis have no unusual predisposing factors in the onset of their disease when compared with matched controls. Also colectomy is usually followed by a marked improvement in preexisting psychiatric illness. Whereas in European reports there is a tendency to consider psychoneuro-sis among the aetiological factors underlying IBD, most American authors feel that anxiety and depression, despite...

One Stage Fistulotomy and Fistulectomy

After excision or incision of a fistulous tract, the wound can be left open for healing by second intention. In some cases, a partial suture at the level of the pectineal line and anoderm may achieve haemostasis, speed up healing time and prevent an anal key-hole deformity. The outer part of the excision is left open to ensure drainage. The wide inter-study variability in success rates of surgery probably depends on the non-homogeneity of the sample of patients treated, but might also depend on the type of fistula treated. Makowiec et al. 66 found the healing rates after surgical treatment of low perianal, transsphincteric and high perianal fistulae to be 64, 40 and 33 , respectively. Moreover, absence of active rectal Crohn's disease decreased the recurrence rate and increased the probability of complete healing. Due to the high incontinence rate and keyhole deformity generated by these procedures, we prefer to use the advancing flap technique in cases of Crohn's perineal fistulae,...

Colocutaneous Fistulae

Resection of the large intestine caused by Crohn's disease 52 , whereas a surveillance period that lasted 10 years showed a 66 chance 60 , and a surveillance period of 14 years showed an 86 chance for recurrence 60 . The types of surgical procedures performed on the large intestine include segmental resection, left and right hemicolectomy, sigmoid resection and anterior rectal resection, colectomy with ileo-rectal anastomosis, colectomy with ileostomy and proctocolectomy. Interpretation of the results can be difficult because inclusion criteria in some trials are not homogenous therefore, patients with segmental resection are enrolled in the same group with those who underwent subtotal colectomy with ileostomy or just stoma formation (61-63). The latest reports show that recurrence following segmental resection required repeated surgical treatment in 30-49 of patients 21, 61, 64 . The lowest level of recurrence at 15 has been noted for patients after right-sided hemicolectomies 61 ....

Risk of Cancer and Endoscopic Surveillance

The first description of a cancer of the colon complicating regional enteritis was described in 1948 79 . After this, published works abounded with reports of colorectal cancer in series of patients with Crohn's disease 80 . In a recent population-based study 81 , Bernstein et al. determined the incidence of cancer by linking records from the IBD and non-IBD cohort with the Comprehensive Cancer Care Manitoba Registry. IBD patients were matched 1 10 to randomly selected members of the population without IBD based on year, age gender and postal area of residence. There was an increased risk of colon carcinoma for both Crohn's disease patients 2.64 95 confidence interval (95 CI), 1.69-4.12) and UC patients (2.75 95 CI, 1.91-3.97 . There was an increased IRR of rectal carcinoma only among patients with UC (1.90 95 CI, 1.05-3.43) and an increased IRR of carcinoma of the small intestine only in Crohn's disease patients (17.4 95 CI, 4.16-72.9). An increased IRR of extraintestinal tumours was...

Gluteus Maximus VY Advancement Flaps

Shallow perineal defects may be closed utilising single or bilateral gluteus maximus V-Y flaps. The origins of the gluteal muscles are detached from their attachment to the sacrum, advanced medially and secured to each other in the midline. A V-shaped incision is made in the posterior lateral buttock skin down to the gluteal muscle. The musculocutaneous unit is advanced medially and a midline closure is performed without tension. The donor site is closed as a V-Y plasty 18 . Hurst et al. 19 utilised this flap in 4 of 12 patients (12.4 of 97 patients submitted to proctectomy for Crohn's disease) achieving primary closure.

Anti Inflammatory Medications

Several studies demonstrated that sulphasalazine and mesalazine are efficacious at high dose (3 g or more) for CD, but there is no evidence that these drugs are effective in fistula healing. Also corticosteroids have no proven efficacy in the treatment of fistulizing Crohn's disease. In most of the studies on steroid efficacy, patients were not randomized for fistulae 9 . A recent review 10 has associated in patients with fistulizing CD, the use of corticos-teroids with deleterious outcome, including an increased incidence of surgery in two large uncontrolled clinical trials 11,12 . In the European Cooperative Crohn's Disease study, three out of five CD-related deaths were in patients with a palpable abdominal mass receiving 6-methylprednisolone. Corticosteroids may mask clinical signs of an abdominal abscess with the attendant risk of delayed drainage 13,14 . Patients with enterovesical fistulae failed to heal when on steroids 15 .

Epidemiology and Pathogenesis

Genetic factors have been shown to play an important part in the causation of both UC and CD and they have a stronger link to the latter. The relative risk to a sibling of a patient with Crohn's disease is 13-36 and for ulcerative colitis it is 7-17 18 . Additionally, it is estimated that between 6 and 32 of patients with inflammatory bowel disease have an affected first or second-degree relative 19 .

Stenosis of Pouch Anal Anastomosis

Ogunbiyi's study 9 on 198 PRs reports nine cases of OO due to stenosis of the pouch-anal anastomosis in four, LEL in two, prolapse of the pouch in one and stenosis of the remaining ileum above the pouch in two cases. All patients with stenosis of the pouchanal anastomosis underwent a reconstruction of the reservoir with success in three patients out of four. A pouchpexy was performed with success in the patient with prolapse of the pouch. In the two patients with LEL, the efferent limb was successfully removed. In the two cases of stenosis above the pouch, one patient showed no improvement of clinical conditions after the construction of a pouch-anal anastomosis L L, while for the other patient who was diagnosed with Crohn's disease after the construction of the reservoir, the resulting strictureplasty was successful.

Macroscopic Features of IBD

Pseudo Polyp Image

With the progression of the disease, broad-based ulceration of the mucosa develops, separating isolated islands of mucosa which could be inflamed or show features of regeneration. They may be seen to be protruding into the lumen to create the so-called pseudo-polyps commonly seen in this disease. We discourage the use of the term pseudo-polyp as a polyp is a mucosal protrusion and the surviving islands often undergo regenerative or inflammatory changes, and thus can be regarded as polyps. We therefore designate these polyps as either inflammatory, regenerative polyps or polypoid mucosal tags. These polyps are typically small and multiple however, sometimes they can attain a large size mimicking carcinoma 55 . These polyps do not correlate with the disease severity and are not precancerous. Commonly, the ulcers are aligned along the long axis of the colon. In chronic cases or in cases where the disease has healed, the mucosa shows atrophy with flattening of the surface and becomes...


MR imaging is an emerging technique in this field and is expected to play a role similar to that of CT. The clinical efficacy of MR imaging has been investigated, and favorable results have been reported as described in this article. High soft-tissue contrast, static and dynamic imaging capabilities, and the absence of ionizing radiation exposure represent the advantages of MR imaging over CT. On the other hand, MR imaging is more time consuming, less readily available, and more expensive 36-39 . Advantages of CT over MR imaging include greater availability, shorter examination times, flexibility in choosing imaging thickness and planes after data acquisition with multidetector row CT, and higher spatial resolution. Precise indications for MR imaging in the diagnosis of Crohn's disease and its use as a complement to CT or other imaging procedures need further investigation. Clinical management decisions might be influenced by the presence of unsuspected additional lesions that were...

Risk Factors

A recent study suggested that appendectomy performed before CD diagnosis can predict a worse clinical course of disease and a higher risk of resec-tive operations for these patients. In addition, disease localisation seems to be influenced by the occurrence of a previous appendectomy, resulting in a significantly lower frequency of Crohn's colitis (9.8 vs. 27.3 , OR 0.3) compared with controls. This fact may suggest some hints on the pathogenic role of the appendix in CD it could be hypothesised that an etiopathogenic process may be phenotypically expressed in the form of appendicitis avoiding the expression of CD in the colon, similar to the protective role of appendectomy regarding the development of UC. In addiction, the occurrence of an appendectomy before CD diagnosis seems to show a negative association with articular manifestations

Pattern of Disease

In CD, the inflammation is classically patchy, transmural and may affect any part of the gastrointestinal tract. It is usually defined by its location such as terminal ileitis, colonic, upper gastrointestinal etc., or by the pattern of the disease inflammation, which could be infiltrating or stricturing. These variables are combined in the Vienna classification, which veers from the original anatomic classification of CD. The Vienna classification is a simple and objective classification of Crohn's disease and encompasses different variables such as age at onset, location and disease behaviour 47 . Application of the Vienna classification has demonstrated that in CD the process changes with time and 80 of inflammatory diseases ultimately evolve into a stricturing or penetrating pattern and about 15 undergo a change in anatomical location (Table 1) 48 . A new classification is under consideration following the 2005 World Congress at Montreal and it is envisaged to be a combined...


The American Society for Gastrointestinal Endoscopy (ASGE) recommends that patients with UC who have pancolitis should begin surveillance colonoscopy after 8 years of disease. Four biopsies should be obtained every 10 cm from the cecum to the rectum. In addiction, any suspicious lesions or masses should be biopsied. Colonoscopy should be repeated every 1-3 years. The finding of carcinoma or high-grade dysplasia is an indication for colecto-my. Colectomy is also indicated for any degree of dysplasia associated with lesion or mass. However, in patients in whom colectomy is not feasible or is unacceptable, frequent surveillance, every 3-6 months, is considered an acceptable alternative. For patients with left-sided colitis, the ASGE recommends that surveillance should begin after 15 years of disease. Surveillance is not indicated in ulcerative proctitis. In CD, the risk of colorectal cancer is increased only in regard to Crohn's colitis. Surveillance colonoscopy and biopsy for dysplasia...

Hman In Vb Studies

Another study evaluating visceral sensitivity in patients with ileal Crohn's disease presented evidence for reduced pain sensitivity, possibly related to descending bulbospinal inhibition of sacral dorsal horn neurons in response to chronic intestinal tissue irritation 33 . The presence of a hyposensitive rectum in CD was already observed by some authors years ago, where almost half of patients with a nor


Most frequent site of the disease, accounting for about 70 of cases. Of these, 20-30 involved the colon only, and 40-55 had ileocolic disease 12 . Although considered peculiar of Crohn's colitis, rectal sparing is found in less than half of patients. When the rectum is involved, the disease begins at the rectosigmoid junction or appears with anorectal inflammation. The entire rectum is affected by the disease from 5 to 10 . Lesion progression, from aphthous to serpiginous ulcers, has a discontinuous and asymmetric course, with the inflamed mucosa typically presenting normal skip areas 13 . Segmental localisation of the disease has a high predictive value 14 . Other endoscopic features found during a colonoscopy include pseudopolyps, erosions and stenosis. A prospective study evaluated the incidence of different lesions found during a colonoscopy. All the patients were affected by Crohn's disease and underwent the procedure before beginning therapy. Endoscopy showed the following...

FollowUp of US

Disease standing is an independent risk factor for CRC development in patients suffering from UC. There is no standard definition for the duration of UC. Although some studies define duration based on the date of radiological, endoscopic or histological diagnosis, a preferred approach is to define it in relationship to the onset of UC-like symptoms. Since the risk of CRC becomes greater than in general population after 8-10 years from disease onset 12 , the Crohn's and Colitis Foundation of America (workshop Colon cancer in IBD science and surveillance, Palm Harbor, Florida, March 2000recom-mends that a screening colonoscopy be performed 8-10 years after onset of symptoms attributable to UC to redefine extension and cutoff dysplasia. Then, a regular surveillance program should be carried out.


Bernstein et al. 17 , in an open study with metronidazole 20 mg kg day on patients with longstanding perianal fistulae, observed an initial clinical response in 20 21, with complete healing at 8 weeks in 56 of cases. However, at follow-up, 78 of these patients recurred 4 months after discontinuation and only 5 of 18 patients could discontinue the metronidazole 18 . Other open studies with metronidazole confirmed closure rates of perianal Crohn's fistula of 35-50 19-21 . Clinical improvement is usually seen within the first 6-8 weeks. So far, no controlled trials have been performed on the short and long-term efficacy of metronidazole on fistulae healing. Based on a cost-utility analysis 21 , metronidazole in combination with an immunomodulatory medication, such as azathioprine (AZA), may be the most cost-effective initial therapy for fistulizing CD. Metronidazole is often poorly tolerated because of adverse effects including paresthesias, dyspepsia, a metallic-taste and a...

Cyclosporine A

Present and Lichtiger 38 treated 16 patients with Crohn's fistulae (10 perirectal, 4 enterocutaneous, 2 rectovaginal) with cyclosporine A, starting with a continuous intravenous infusion (4 mg kg day), switched to the oral route (6-8 mg kg day). Fourteen responded to parenteral CyA (7 complete closure, 7 moderate improvement) and discontinued the steroids, with a mean time for response of 7.4 days. When switched to the oral route, 64 remained in remission, 36 relapsed. These results have been supplemented by a review of literature including 39 patients with fistulizing Crohn's disease who have been treated with CyA 43 . Within this group, 90 responded to intravenous cyclosporine, but 82 relapsed with CyA suspension. On the base of these studies, it is reasonable to use CyA in fistulizing Crohn's disease in the acute phase as it will not achieve long-term response, all patients should be treated with concurrent AZA 6-mercap-topurine for maintenance or, if the patient is allergic...


Infliximab has also proved to maintain its efficacy in the long term. In a randomized controlled trial of 573 patients with active Crohn's disease (CDAI score of at least 220), responders to a 5 mg kg i.v. of infliximab (335 patients) were randomly assigned to repeat infusions of placebo at weeks 2 and 6 and then every 8 weeks until week 46 (group I), or 5 mg kg infliximab at the same timepoints (group II), or 5 mg kg infliximab at weeks 2 and 6 followed by infliximab 10 mg kg (group III). At week 30, 21 of the patients of group I were in remission, compared to 39 of group II and 45 of group III 58 . In a recent analysis of Crohn's disease, patients treated with infliximab in ACCENT I, episodic and The long-term use of infliximab for fistulizing CD is still under investigation in terms both of a limited efficacy and cost-effectiveness. As for the first problem, Poritz et al found that, if clinical improvement was obtained in 18 out of 26 patients with fistulizing CD, with complete...

Biological Treatment

There are a number of trials on the effectiveness and safety of infliximab treatment. One of the better ones is the prospective ACCENT (a Crohn's disease clinical trial evaluating infliximab in a new long-term treatment regimen). The study included CD patients from North America, Europe and Israel.

Risk of Carcinoma

Similar to ulcerative colitis, CD is a risk factor for development of colorectal cancer 75, 76 . The risk is higher than in general population, and increases with time 77 . Patients with early Crohn's disease who are younger than 25 years of age are at the higher risk for tumour development 78 . Dysplasia precedes development of the colorectal cancer 79 which in a majority of cases shows a clear tendency to develop at the site of the inflammation. In one third of all The first case of a large intestine tumour connected with Crohn's disease was described in 1948 83 . Since then, publications have recorded a couple of hundred similar cases. Patients with intense and intensifying inflammatory changes of the intestine, forming a background for basic long-lasting disease, are at a significantly increased risk of cancer. This is also true for those who have not had surgery for a pathologically affected segment that had been deemed necessary to remove 80, 83, 84 . It is believed that, due to...

Free Perforation

Large intestine perforation rarely takes place in Crohn's disease. The frequency of large-intestine perforation in patients with Crohn's disease has reached 1.8-2.4 99,100 , making up 20-50 of all digestive tract perforations in Crohn's disease. Typical symptoms of perforation may be hidden behind the effects of high dosages of steroids, thereby delaying early diagnosis. Perforation takes place most often during the course of toxic colitis (with or without toxic megacolon) or during a severe exacerbation of inflammation especially if accompanied by stenosis below the site of perforation. Iatrogenic damage of the inflamed colon during colonoscopy may also be the cause of perforation. Due to the frequent occurrence of intraperitoneal adhesions, some perforations are covered. Surgical treatment depends on the general condition of the patient, the site of the perforation, and the circumstances that caused it. In toxic colitis perforations, colectomy with ileostomy is a recommended...

Emergency Surgery

Intraperitoneal abscess in Crohn's disease in most instances results from perforation or intestinal fistu-lae located in the small intestine. A large intestinal cause of abscess is most often a complication resulting from previous surgical procedure. In the case of elective procedures, the most likely cause lies in leakage of the anastomosis in the case of emergency procedures, it results from peritonitis. Current advancement in invasive radiology makes transdermal drainage, in addition to traditional surgical drainage, possible. Transdermal drainage allows for the attainment of clinical improvement before indications for necessary surgical treatment arise. The disadvantages of transdermal drainage include the risk of fis-tulae and recurrent abscess additional limitations come from technical inability in the transdermal drainage of some areas. Obstruction in Crohn's disease is a frequent occurrence, but only 5-17 is caused by the pathological changes in a large intestine 104 ....


Containing preparations for medical prophylaxis against postoperative recurrence. The largest was conducted as part of the European Cooperative Crohn's Disease Study 25 . A total of 318 postoperative patients were randomized to receive mesalamine (Pentasa 4 g day) or placebo, and were followed for 18 months. Clinical recurrence occurred in 24.5 of treated patients and 31.4 in the placebo group. This trend was not statistically significant (P 0.10) in the group as a whole but was significant in those patients with isolated small-bowel disease.


Corticosteroids have no benefit as a maintenance therapy 31 . Over the past 10 years, a newer steroid, budesonide, which showed several features that made it particularly suitable for study as a long-term anti-inflammatory agent in Crohn's disease, has generated interest. It has a high first-pass hepatic metabolism and high steroid receptor affinity. Controlled release preparations were developed that delivered high ileal concentrations of the drug taken orally to produce considerable topical anti-inflammatory activity with a decreased systemic effect 31 .


Many patients with anorectal Crohn's disease present other intestinal locations of the disease, requiring an evaluation of the colon and small bowel. The presence of proximal disease poses a therapeutic dilemma early reports suggest that perianal conditions persist in the presence of proximal disease and improve only if proximal disease is resected 10,11 however, other reports refute these findings and One multicentre study reviewing treatment of patients with perianal Crohn's disease shows medical treatment to be curative in only a few patients, whereas surgical procedures were curative in more than half of the patients 17 . A role for both approaches exists and success is attributed to careful patient selection, limited surgical intervention, and improved perioperative medical management 18,19 .


Faecal incontinence in patients with perianal Crohn's disease is common, occurring in 39 of patients 32 . Management of this condition is challenging because the cause is often multifactorial. The incontinence may be secondary to severe perineal Crohn's disease associated with chronic fibrosis and scarring of the anorectum resulting in loss of reservoir function. In this situation, faecal diversion or proctectomy is indicated. If the patient suffers from severe Crohn's-related muscle destruction, a colostomy is indicated. Diarrhoea from colonic disease or short-bowel syndrome also may lead to incontinence and may require a colostomy if diarrhoea and stool consistency cannot be controlled. On the other hand, incontinence may be unrelated to Crohn's disease and may be caused by obstetric injury or an overly aggressive surgery such as fistulotomy. The cause may become evident based on medical history and physical examination. Complementary examinations such as anal manometry,...

Anorectal Cancer

The risk for squamous-cell carcinoma of the anus is not increased in patients with perianal Crohn's disease 15, 35 . The presence of inflammation may delay the diagnosis of cancer, so in any patients with persistent perineal ulcers or fissures that fail to heal, a biopsy of the lesion should be considered. An association exists between colorectal cancer and Crohn's disease. 36 . A long duration of illness and the presence of chronic perianal disease may increase the risk for rectal malignancy 15, 37-39 . The risk for colorectal cancer is not confined just to areas of inflammation in addition the risk for rectal cancer may be increased if the rectum has been excluded from intestinal flow or placed out of intestinal continuity. This is similar to the increased cancer risk in bypassed segments of small bowel 38, 40 . Lavery and Jagel-man 41 identified two cases of cancer that developed in the out-of-circuit rectum after subtotal colectomy and colostomy for Crohn's disease. Because of...


The first step consists of coring out the entire fistu-lous tract from the external to the internal opening (Fig. 8a). The intersphincteric space is curetted. The gap through the external and internal sphincters is closed by separate stitches of absorbable material starting from the anal lumen (Fig. 8c). The mucosa and anoderm, depending on the level of the tract, are excised around the internal opening. A flap of mucosa is undermined (Fig. 8b). The size of the flap must have a base which is twice the width of the apex, but the length should be as short as possible to reduce the risk of ischemia. The flap is sutured to the lower edge of the mucosa (Fig. 8d). The suture line must lie distal to the previous muscle closure. The external wound is left open. If the wound below the pectineal line cannot be totally closed, the flap is sutured to the muscles below the previous opening 69 . No stoma is necessary. The external wound should be cleaned at least twice daily with saline and some...

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