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General Principles of Medical and Surgical Management of Inflammatory Bowel Disease

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

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  1. General Principles of Medical and Surgical Management of Inflammatory Bowel Disease Jeraldine S. Orlina Colorectal Conference December 22, 2005

  2. Medical Therapy of Ulcerative Colitis • 5-Aminosalicyclic acid agents • Corticosteroids • Cyclosporine • 6-Mercaptopurine • Azathioprine

  3. 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

  4. Operative Indications • Failure of medical therapy • Obstruction • Fistula or abscess • Hemorrhage • Growth retardation (in pediatric population) • Perforation of carcinoma • Extraintestinal manifestations

  5. 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

  6. Preparation of patient • Withdrawal of immunosuppressives • Perioperative antibiotics • Stress dose steroids • DVT prophylaxis

  7. 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

  8. Management of Small Bowel Crohn’s Diesease • Chronic obstruction (35%) • Internal fistulas (30%) • Intractability (22%) • Abscess formation (11%)

  9. Types of Operations • Small bowel resection • Multiple small bowel resections (with enteroenterorostomy, diversion, or both) • Bypass • Strictureplasty • Balloon dilatation

  10. Resection • Most common surgical procedure • Wide resection unnecessary • Division of inflamed mesentery

  11. 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

  12. 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

  13. Heineke-Mikulicz Strictureplasty

  14. Finney Strictureplasty

  15. Side-to-side isoperistaltic strictureplasty

  16. Stapled Strictureplasty

  17. Complications • Hemorrhage form suture line • Restricture at strictureplasty site • Fistula/Abscess/Leak • Small bowel adenocarcinoma

  18. Take Home Points • Conservative Management • Preservation of small bowel

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