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General Principles of Medical and Surgical Management of Inflammatory Bowel Disease. Jeraldine S. Orlina Colorectal Conference December 22, 2005. Medical Therapy of Ulcerative Colitis. 5-Aminosalicyclic acid agents Corticosteroids Cyclosporine 6-Mercaptopurine Azathioprine.
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General Principles of Medical and Surgical Management of Inflammatory Bowel Disease Jeraldine S. Orlina Colorectal Conference December 22, 2005
Medical Therapy of Ulcerative Colitis • 5-Aminosalicyclic acid agents • Corticosteroids • Cyclosporine • 6-Mercaptopurine • Azathioprine
5-Aminosalicylic Acid Agents • Sulfasalazine - 5-ASA linked to sulfapyridine by an azo bond - poorly absorbed in upper GI tract - principle use to maintain remission
Operative Indications • Failure of medical therapy • Obstruction • Fistula or abscess • Hemorrhage • Growth retardation (in pediatric population) • Perforation of carcinoma • Extraintestinal manifestations
Preparation of the Patient • Endoscopic and Radiologic studies • Correction of dehydration, electrolyte deficiencies, coagulation deficits, and anemia • Optimization of comorbid conditions • Nutritional optimization • Pre-op marking for stoma (if needed) • Bowel prep
Preparation of patient • Withdrawal of immunosuppressives • Perioperative antibiotics • Stress dose steroids • DVT prophylaxis
Strategic Planning for Surgery • Midline incision to preserve potential stoma sites • Preservation of small bowel • Resection margins—extended resection margins are unnecessary • Use of temporary stoma
Management of Small Bowel Crohn’s Diesease • Chronic obstruction (35%) • Internal fistulas (30%) • Intractability (22%) • Abscess formation (11%)
Types of Operations • Small bowel resection • Multiple small bowel resections (with enteroenterorostomy, diversion, or both) • Bypass • Strictureplasty • Balloon dilatation
Resection • Most common surgical procedure • Wide resection unnecessary • Division of inflamed mesentery
Indications for Strictureplasty • Diffuse involvement of small bowel with multiple strictures • Strictures in a pt who has undergone prev major resection of small bowel • Rapid recurrence of disease manifested as obstruction • Stricture in pt with short bowel syndrome • Nonphlegmonous fibrotic stricture
Relative Contraindications for Stictureplasty • Free or contained perforation of the small bowel • Phlegmonous inflammation, internal fistula, or external fistula involving the affected site • Multiple strictures within a short segment • Stricture in close proximity to a site chosen for resection • Colonic strictures • Hypoalbuminemia
Complications • Hemorrhage form suture line • Restricture at strictureplasty site • Fistula/Abscess/Leak • Small bowel adenocarcinoma
Take Home Points • Conservative Management • Preservation of small bowel