Information about Inflammatory Bowel Disease by Dr Dhaval Mangukiya. Details of brief overview of the talk, Surgery in crohn's disease, Scenarios, Localised ileal or ileocaecal disease, Coincidental ileitis, Localised or multifocal colonic disease, Concomitant abscess, Surgical considerations, Anastomotic technique, Laparoscopy etc. https://drdhavalmangukiya.com/ http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat https://gastrosurgerysurat.blogspot.com/

1. Inflammatory bowel disease –
When to operate and
how to avoid complications?
Dr Dhaval Mangukiya
Surgical Gastroenterologist
SIDS Hospital & Research Center

2. Brief overview of the talk
• Indications of surgery in Crohns
• Technical considerations of surgery in Crohns
• Indications of surgery in ulcerative colitis
• Technical considerations of surgery in UC
• Drugs and their influence on surgical
complications

3. Surgery in Crohn’s disease
General Principles:
• With current medical treatment available,
surgery has a role only to treat complications
• Aim at bowel preservation.
• No role of resecting upto healthy bowel
margins.
• Leave diseased bowel behind, just deal with
the part of the bowel responsible for the
symptoms that invoked surgical treatment

4. Scenarios
• Localised ileal – ileocaecal disease
• Coincidental ileitis
• Localised colonic disease
• Multi segmental colonic disease
• Concomitant abscess

5. Localised ileal or ileocaecal disease
• Inflammatory only:
– crohns without obstructive symptoms should be
treated medically – usually show good response to
steroids
• Inflammatory – obstructive:
– If refractory obstructive symptoms despite steroids –
consider surgery
• Obstructive only :
– primary surgery (rule out inflammatory pathology by
endoscopy, S. CRP)
ECCO guidelinesECCO guidelines – Management
of Crohn’s disease 2015

6. Localised ileal or ileocaecal disease
• Upto 50% patients who underdo surgery for
ileal or ileocolic disease require surgery again.
• Following Ileo-caecal resection , strictures
should be treated by colonoscopic dilatation
Weston LA, et al. Ileocolic resection
for acute presentation of Crohn's disease of the ileum. Dis
Colon Rectum 1996;39:841–6.
Hassan C, et al.
Systematic review: endoscopic dilatation in Crohn's disease.
Aliment Pharmacol Ther 2007;26(11–12):1457–64.

7. Coincidental ileitis
• Refers to the finding of terminal ileal or caecal
inflammation at laparoscopy or laparotomy
for other causes like appendicitis
• Resection not justified unless laparotomy for
obstruction
• Reemphasizing the point that treatment of
inflammatory crohns is NOT surgery
ECCO guidelinesECCO guidelines – Management
of Crohn’s disease 2015

8. Localised or multifocal colonic disease
• Strictureplasty in the colon is not recommended
• Main issue is that strictures may harbour
malignancy
• Resection is the only surgical option
• Localised disease – segmental colonic resections
• Multifocal disease –
– Subtotal colectomy and ileorectal anastomosis
– Two segmental resections
Both options may be feasible.
ECCO guidelines – Management
of Crohn’s disease 2015

9. Concomitant abscess
• Penetrating nature of Crohns results in abscesses in
interbowel region, mesentry, pelvis or retroperitoneum
• First attempt should be image guided percutaneous drain
• Continuation of medical treatment
• Surgery only if inadequate drainage or presence of obstructive
symptoms
• However a lot of studies show that about 50% patients
treated with percutaneous drainage eventually require
surgery
ECCO guidelines – Management of Crohn’s disease 2015
Garcia JC, . Abscesses inCrohn's disease: outcome of medical versus surgical
treatment. J Clin Gastroenterol 2001;32:409–12

10. Surgical considerations
• Strictureplasty is the
recommended approach for
small bowel strictures
• Conventional stricturoplasty
(Heineke – Mikulicz) is advised
when the length of the stricture
is <10 cm
• Few series however show that
unconventional strictureplasty
(Finney) can be done safely for
strictures longer that 10 cm

12. Anastomotic technique
• Following metaanalysis has shown that a side to side
anastomotic configuration following resection had a
lesser leak rate compared to conventional end to
end.
• No difference between leak rates of stapled side to
side vs hand sewn side to side anastomosis seen.
• A wide anastomotic lumen may be the discriminating
factor
Simillis C,. A meta-analysis comparing conventional end-to-end
anastomosis vs. other anastomotic configurations after resection
in Crohn's disease Dis Colon Rectum 2007;50(10).
Scarpa M, et al. Role of stapled and hand-sewn anastomoses in
recurrence of Crohn's disease. Hepatogastroenterology 2004;51.

14. Laparoscopy
• Metanalysis comparing laparoscopic vs open
approaches in Crohns disease have shown lesser
morbidity
• ECCO recommends laparoscopic approach at centres
where it is available.
• In complex cases like abscesses, fistulae and
recurrence however, an open approach may be safer
Tilney HS, et al. Surg Endosc 2006;20(7):1036–44.
Lesperance K, J Gastrointest Surg 2009

15. Surgery in Ulcerative colitis
• UC affects only the large bowel
• Overall risk of malignancy higher than Crohns
• Chances of recurrence minimised when all the
large bowel is removed ( compare with Crohns
where surgery never influences recurrence)
• Main Principle of Surgery in UC is to remove
all the large bowel whenever surgical option is
chosen

16. Indications
• Emergency
– Acute severe colitis
– Toxic megacolon
– Hemorrhage, perforation
• Elective
– Refractory colitis
– Malignancy or dysplasia

17. Acute severe colitis
• Defined as bloody diarrhoea ≥6/day and any
signs of systemic toxicity (tachycardia >90
bpm, fever >37.8 °C, Hb >10.5 g/dL, or an ESR
>30 mm/h)
• Require admission and joint assessment by
gastroenterologist and colorectal surgeon
from Day1.

18. Acute severe colitis
• 1 st line of treatment is IV corticosteroids
• 2nd line is cyclosporin or infliximab or
tacrolimus.
• Decision on indication and timing of surgery
often difficult to take.

19. Acute severe colitis
• Response to intravenous steroids is best assessed on
day 3.
• Second line therapy with either ciclosporin, or
infliximab or tacrolimus may be appropriate at this
stage
• If there is no improvement within 4–7 days of
salvage therapy, colectomy is recommended
• Colectomy as an option should be discussed with
patients on day 3 if there is no response to steroids
Dignass A, et al, Second European evidence-based Consensus on the diagnosis and
management of ulcerative
colitis: Current management, Journal of Crohn's and Colitis (2012

20. Predictors of requirement of colectomy in
acute severe UC
• Clinical and Biochemical
criteria
– frequency >8/day with a
CRP >45 mg/L on day 3
(Oxford Criteria)
– stool frequency ×0.14
CRP being ≥8 on day 3
(Sweden Index)
– An ESR >75 or a pyrexia
>38 °C on admission
• Radiological/
endoscopic criteria
– colonic dilatation >5.5
cm
– mucosal islands on a
plain abdominal
radiograph
– Endoscopic criteria
although exist -- use not
recommended as
endoscopy to be avoided
in acute setting
Dignass A, et al,, Journal of Crohn's and Colitis (2012

22. Management of acute severe ulcerative colitis
Saurabh Kedia, Vineet Ahuja, Rakesh Tandon
World J Gastrointest Pathophysiol 2014
November 15; 5(4): 579-588

23. Toxic
megacolon
• Defined as total or segmental
non-obstructive dilatation of the
colon ≥5.5 cm associated with
systemic toxicity
• Risk factors include
hypokalaemia,
hypomagnesaemia, bowel
preparation, and the use of anti-
diarrhoeal therapy.
• Limited window of opportunity
for medical treatment to work
and usually early colectomy is
necessary

24. Refractory colitis
• Patients with endoscopically documented active colitis who
fail oral corticosteroids combined with oral and rectal 5-ASA
therapy have refractory proctitis or distal colitis
• Therapeutic options:
– Admission and IV steroids
– Salvage therapy – cyclosporine, tacrolimus, infliximab
– Other therapies may be tried like – short chain fatty acid enemas,
lidocaine enemas, acetarsol (arsenic) suppositories but lack good
evidence
• If disease persists in spite of these approaches, surgery is
likely to be the outcome
Dignass A, et al,, Journal of Crohn's and Colitis (2012

25. Technical considerations of surgery in
UC
• Restorative proctocolectomy with ileal pouch
anal anastomosis is the current standard of
care as a definitive surgery in ulcerative colitis
• Whether to perform it as a single, double or
three staged surgery depends on the clinical
setting
• Proctocolectomy with end ileostomy may be
considered in the elderly

26. Restorative Proctocolectomy

27. Technical considerations of surgery in
UC
Acute severe colitis
• A staged proctocolectomy (subtotal colectomy with
end ileostomy first) is recommended in acute severe
colitis
ESPECIALLY
• if a patient has been taking 20 mg daily or more of
prednisolone for more than 6 weeks
• Pelvic dissection best avoided and the whole rectum
and the inferior mesenteric artery should be
preserved

28. Technical considerations of surgery in
UC
Acute severe colitis
Managing the rectal stump:
• Leaving as little rectum as possible is not to be
recommended
• Best is to divide at level of distal sigmoid and bring
out the distal stump in the subcutaneous tissue
either closed or as a mucus fistula
Dignass A, et al, Second European evidence-based Consensus on the diagnosis and
management of ulcerative
colitis: Current management, Journal of Crohn's and Colitis (2012

29. Technical considerations of surgery in
UC
Site of anastomosis for restorative proctocolectomy:
• ECCO recommends the maximum length of anorectal mucosa between the
dentate line and the anastomosis should not exceed 2 cm
Hand sewn vs stapled
• Following large metaanalysis shown no difference in leak rates.
• Physiological function of sphincter and nocturnal continence better in
stapled group
• Literature shows no difference in incidence of dysplasia or cancer in both
groups
• Supposition that stapled anastomosis leaves rectal mucosa increasing risk of
malignancy IS NOT TRUE
Lovegrove RE, et al . A comparison of hand-sewn versus stapled ileal
pouch anal anastomosis (IPAA) following proctocolectomy: a meta-analysis of 4183
patients. Ann Surg. 2006

30. Technical considerations of surgery in
UC
Role of covering ileostomy for restorative
Proctocolectomy
• ECCO recommends covering ileostomy
following restorative proctocolectomy with
IPAA
• Exception – doing ileostomy difficult due to
short mesentry or thick abdominal wall

31. Surgical choices in addition to restorative
proctocolectomy
• Whilst advancing age may lead to poorer outcome, no defined
age limit for performing an IPAA can be recommended
• The continent ileostomy is still a viable option that can be
used when there is no possibility of performing an ileal pouch
anal anastomosis, or when the IPAA fails
• An ileorectal anastomosis should be considered only in special
cases (such as for reasons of fertility). Long term surveillance
of the retained rectum is advised

32. Brooke Ileostomy

33. Continent ileal reservoir

34. Role of laparoscopy
• Now an abundance of data to suggest that a
laparoscopic approach to IPAA is both feasible and
safe
• No RCT yet demonstrating obvious benefit over open
• A Cochrane review has demonstrated better short
term benefits of laparoscopic approach but evidence
poor due to lack of RCTs
Ahmed Ali U,, et al. Open versus laparoscopic (assisted) ileo pouch
anal anastomosis for ulcerative colitis and familial adenomatous
polyposis. Cochrane Database Syst Rev 2009;

35. Pouch surgery for indeterminate colitis, or IBD
yet-to-be classified
• Data suggests higher incidence of pouch related
complications when it is done for indeterminate
colitis
• ECCO recommendation: IPAA may be considered in
cases of indeterminate colitis but patient should be
counselled prior about high failure rate and poor
QOL.
• The QOL may not improve much after pouch excision
due to redo pelvic surgery causing inevitable
autonomic nerve damage and its effects

36. Drugs and their effect on post surgical
complications
• Prednisolone 20 mg daily or equivalent for more than six
weeks is a risk factor for surgical complications. Therefore,
corticosteroids should be weaned if possible
• Pre-operative thiopurines do not increase the risk of
postoperative complications
• Perioperative use of infliximab does not appear to increase
the risk of infective complications. There may however be an
increase in short term surgical complications
• Data for cyclosporin, tacrolimus limited.
Dignass A, et al,, Journal of Crohn's and Colitis (2012

37. Case presentation
Inflammatory bowel disease
Dr Subhash Nandwani
Dr Dhaval Mangukiya
SIDS Hospital

38. History
• 29 yr old male, chronic smoker
• Pain in the abdomen mainly localised to the RIF
• Watery diarrhoea, occasional blood
• Vomiting off and on
• Feverishness, fatigue
• Wt loss 4 kg in 3 months.
• Past history peri-anal abscess requiring drainage
2yrs ago
• H/O Tuberculous pleural effusion at 12 yrs of age

39. O/E
• Vague mass in right lumbar region
• Hyperperistalsis
• P/R:Normal
• Healed right sided peri-anal scar

40. Investigations
• Hb 10.5 g/dl, WBC 7600/cmm, Plat 3.5lakh/cmm
• CRP : 68
• ESR : 40 mm at 1 hr
• Stool routine : 15-20 pus cells/hpf, few RBCs, no
ova or parasites, occult blood +ve
• Xray abd: few air fluid levels
*

42. CT SCAN
• Long segment stricture of terminal ileum
• Long segment narrowing of caecum &
proximal ascending colon
• Pericaecal, preiliac LNs –non necrotic*

43. •Small bowel wall
thickening > 3mm
•Bowel thickness correlates
with disease activity
•Markedly thick segments
indicate active disease.
•Predisposition to affect
mesenteric border
•Segmental mural
hyperenhancement
indicates active disease
CROHNS DISEASE

44. Mural thickening with stratification affecting
small bowel with skip areas
Crohn's disease

45. Ileocaecal tuberculosis with extensive necrotic
lymphadenopathy

46. Colonoscopy
• .
– Nodularity & ulceration of ascending
• colon
– Stricture in ascending colon beyond
• which scope not negotiable
1. Biopsies taken for histopathology and
2. AFB smear and culture, TB PCR*

47. • Histopathology: “Severe chronic colitis”
No granulomas, mild crypt distortion with
inflammation lymphocytes and neutrophils
• AFB Smear negative, TB PCR –ve
• Awaiting AFB culture report

48. • Patient settles with conservative treatment
• Orals re-introduced slowly
• Trial of medical treatment? Emperic
• Surgery?*

49. • Started on Anti -tuberculous drugs –HRZE X 4
weeks
• Not much change in symptoms, comes back
with full blown obstruction
What next?*

50. Surgery and post op course
• Undergoes right hemicolectomy – 18 cm
length of ileum
• Intra-operative findings
thickened bowel, creeping fat, peri-caecal,
non necrotic lymph nodes

51. Investigations
• Specimen histopathology
Chronic ileal and colonic inflammation, few
discrete small granulomas consistent with Crohn’s
disease
• AFB smear and culture from colonic
biopsies/specimen
AFB smear: Negative
AFB culture: Negative

52. • Does he need treatment now for Crohn’s
disease?
• Follow up advice after surgery?

53. At 3 months post operatively,
Well
Gained 5 kg weight
On no medication for Crohn’s
Repeat colonoscopy at 6 months

54. How will you
manage an
anastomotic
recurrence
•

55. Case 2

56. Case 2
• 35 year old lady
• Known case of ulcerative colitis
• Presented with severe diarrhoea of 10 days
duration
• Blood and mucus in stools
• Frequency: 10-12 during day and 4-5 at night
• Urgency ++
• Anorexia, low grade fever

57. Past history
• 1st attack at the age of 30 years (5 yrs back)
• Needed steroids for achieving remission
• Diagnosed to have pan colitis
• Put on mesalazine 2.4 gm
• Another mild attack responding to an increase
in dose of mesalazine 6 months ago

58. On examination
• Averagely nourished
• Pallor+
• P : 110/min
• BP 106/60
• P/A : Abdomen mild deep tenderness
What are the possibilities?*

59. • Hb 8 g/dl
• WBC: 13,300/cmm
• Platelets: 5,34,000/cmm
• Stool routine: plenty of RBCs+, 20-30 pus cells/hpf,
no ova/parasites
• ESR 80 mm
• CRP 70
• LFTs N
• S. creatinine 1.2 mg/dl BUN 80 mg/dl
• S.electrolytes – Normal
What next?

61. Need/safety of sigmoidocopy/colonoscopy?
Any role for imaging?
Role for testing for C. difficle, CMV?

63. C. Difficile toxin –ve
Biopsies – severe active ulcerative colitis, no
CMV inclusions
How will you manage?*

64. • NBM
• Started on IV hydrocortisone 100 mg tid
• IV antibiotics – metronidazole and piperacillin
tazobactam
• Mesalazine 4.8 gm/day, steroid enemas
Monitoring?

65. • No response to IV steroids after 5 days
• What next?
• Cyclosporin vs. Infliximab vs. Surgery

66. Patient undergoes surgery
Has a 1st stage with a total colectomy and ileostomy
and mucous fistula
2nd stage – closure of stoma, resection of rectum,
J pouch ileal reservoir with a stapled ileo-anal
anastomosis
Post op has a frequency of 7-8 per day with 2 at
night – improves over a period of 1 year with
loperamide to about 5-6 in 24 hrs, occasionally nocturnal

67. About a year and half after surgery, presents
with increased frequency, urgency, pain and
bloody diarrhoea
Stool shows 10-12 pus cells /hpf, few RBC
Differential diagnosis?*

68. Pouchoscopy

69. Possibilities
• Pouchitis
• Cuffitis
• Ischemic changes in pouch
• Recurrence of original disease
• Irritable pouch syndrome

72. How would you manage “pouchitis”