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Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is a term used to describe two intestinal conditions, Crohn’s Disease and Ulcerative Colitis that are characterized by inflammation of the lining of different parts of the gut. What is unique about these 2 diseases is that the intestinal inflammation is not caused by infection, drug reaction, radiation, or a lack of blood supply (which are the most common causes of GI tract inflammation). In patients with IBD no clear cause can be found for the intestinal inflammation. Ulcerative Colitis (UC), with few exceptions, involves only the large bowel (colon and rectum) whereas Crohn’s Disease (CD) may involve both the small and large bowel (and rarely the stomach as well).


In UC patients the extent and severity of the bowel inflammation and symptoms varies considerably. In some patients only the rectum is involved; when this is the case, rectal bleeding is the most common symptom. In other patients the rectum and the sigmoid colon are inflamed; the associated symptoms are bloody diarrhea and left sided abdominal pain and cramps. In still other people with UC the whole left side of the colon or the entire colon is diseased. Patients with such extensive involvement may experience widespread abdominal pain and cramping as well as bloody diarrhea, fatigue, and significant weight loss.


Crohn’s Disease, as mentioned, may involve the small bowel and/or the colon. The symptoms that develop depend, in part, on the part or parts of the intestine that are involved. Symptoms include bloody diarrhea, abdominal pain and cramps, weight loss and fatigue. CD patients may develop perforations of the bowel that can lead to abdominal abscesses and abnormal connections between different parts of the intestine called fistulas.


Both UC and CD are initially treated with a variety of medicines. Patients are usually treated by a gastroenterologist with one or more of the following drugs: azulfidine, asacol, pentasa, prednisone (or other steroids), cyclosporine, antibiotics, and infliximab. Azathioprine and 6-MP (6-mercaptopurine) are two other drugs used to treat some Crohn’s disease patients. Most often, during the course of having either CD or UC patients will be placed on a number of different drugs and combination of drugs in an effort to best control the disease. In a percentage of patients, despite these efforts, surgery becomes necessary and advisable.


Reasons for Surgery in Patients with Ulcerative Colitis


Surgery for patients with Ulcerative Colitis is advisable in a number of different situations. UC patients who have recurrent attacks that are lengthy and that do not respond quickly to medical treatment is one example. Patients who become resistant (no longer respond) to IBD drugs or who develop side effects from being on these drugs for long periods of time are another. A third reason for surgery is related to the fact that patients who have had UC for many years are at higher risk for developing a colon or rectal cancer than patients without the disease. Even longstanding UC patients who are not having current attacks are at risk. Such patients are advised to have yearly colonoscopy and multiple “random” biopsies in order to detect early signs that a colon cancer may be developing (dysplasia).


In a small percentage of patients urgent or emergent surgery is needed because of severe colonic bleeding that does not stop despite treatment. Also rarely, patients in the midst of an acute episode of colitis who are not responding to the variety of medications used for CUC will be advised to have an urgent operation. Very rarely, patients with active disease will develop impressive abdominal pain and colonic distension; interestingly, they often stop having bowel movements altogether. This condition is called "toxic megacolon" and it very dangerous because the colon may perforate or rupture. Patients suspected of having toxic megacolon are advised to undergo immediate surgery.


Operations for Ulcerative Colitis


The great majority of patients that come to surgery for UC have disease that involves half or more of their large bowel. Although there are a number of different operations performed for patients with UC, in all of these operations the entire colon is removed. In the vast majority of patients, the rectum is also removed. The most common operation that is done is called a total proctocolectomy with ileal pouch anal reconstruction. In this operation the entire colon and either all or the great majority of the rectum is removed after which the small bowel (which is left intact) is connected to the anus or a very short rectal remnant after being fashioned into a pouch. Because patients undergoing this large operation are at fairly high risk for developing an abscess or “leak” from either the small bowel to anus reconnection or the pouch a temporary ileostomy (stoma) is made. The stoma diverts the stool and intestinal contents through the abdominal wall and into a watertight bag which greatly decreases the chances that a leak or abscess will develop in the pelvis. Several months later, after confirming that the rejoining points at the anus and in the pouch are well healed, the ileostomy is reversed at a second much shorter operation.


After this operation patient will go to the bathroom through the anus in the usual way, however, they usually have between 5-8 BM’s per day. Using a combination of dietary changes and by using drugs to slow down the GI tract it is usually possible for patients to regulate the number of bowel movements to an acceptable level. In about a third of pouch patients soiling (seepage or leakage of small amounts of stool) may occur at night while sleeping or even during the day. For this reason some where pads in their undergarments. A relatively small percentage of patients report major accidents and have poor control. In the end, about 5 % of UC patients who get an ileal pouch will do so poorly that they will decide to have an ileostomy made and will live with the stoma.


Another surgical option for UC patients is to have the entire colon and rectum removed and a permanent ileostomy constructed. As mentioned above, in this situation all of the intestinal contents exit the body through the ileostomy (aka stoma) which is covered continually with a water and air tight bag that can be emptied several ways (see section on colostomy and ileostomy in this web site).


Yet another surgical option for the rare UC patient whose rectum is not diseased is to have the entire colon removed and the small bowel and the rectum reconnected. This avoids an ileostomy but leaves open the possibility that the rectum will develop UC or a cancer in the future.


All of the operations performed for UC can be done laparoscopically. It is Dr. Whelan’s practice to use minimally invasive methods for all elective UC operations.


Surgery for Crohn’s Disease


As mentioned, CD is initially managed by a gastroenterologist with one or several medicines. The drugs used to treat CD include: Azulfidine, Asacol, Pentasa, prednisone (or other steroids), cyclosporine, antibiotics, and infliximab. Surgery is performed only when necessary for problems such as: partial or complete bowel obstruction, intrabdominal abscess or fistula not treatable via other means, and persistent bleeding requiring blood transfusions. Surgery is also advisable in patients with ongoing active CD, manifested by diarrhea, abdominal pain, weight loss, and/or partial bowel obstruction that doesn’t respond to Crohn’s medicines. Finally, in some Crohn’s patients with longstanding disease and chronically narrowed bowel segments that are not causing symptoms, surgery may be advised because of fear that a cancer may be present.


At surgery, the diseased bowel segment(s) is usually resected and the remaining ends of the bowel rejoined. Most commonly, the small and large bowel are the sites of CD. Unlike UC, where the entire colon is usually resected, including parts of the colon that are not diseased (because of the long term cancer risk); in CD only the obviously diseased bowel segments are removed. One important goal of all CD operations is to preserve bowel. If fistulas (abnormal connections between different bowel segments) are found, they are removed or divided. Because CD is often simultaneously present at numerous bowel locations it may be necessary to remove several segments and to perform several anastomoses (rejoining). In some patients, fibtoic scars from past CD attacks cause partial small bowel obstructions that can cause pain, distension, vomiting, and weight loss. At surgery, if scarred narrow areas are found that contain no active inflammation and are not too lengthy, then, instead of resecting that piece of small bowel, the narrowing can be treated by performing a “sticturoplasty” which widens the diameter of the bowel at the site of the narrowing. In a minority of patients a temporary colostomy or ileostomy may be required.


Unfortunately, CD can recur, even after all of the diseased segments are surgically removed. It is important that CD patients remain in the care of a gastroenterologist before and after surgery.


All of the operations performed for Crohn’s can be done laparoscopically. It is Dr. Whelan’s practice to use minimally invasive methods for all elective CD operations. However, because CD patients often have had numerous prior operations and because of the nature of the disease, severe adhesions and sizable masses may be encountered which may make laparoscopic completion of the operation impossible or ill-advised. In these patients, after starting the operation laparoscopically, conversion to a standard open “big incision” operative approach may be necessary.

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Our family wishes to express our heartfelt appreciation for the kindness, excellent care and wisdom our mother, Jean Broussard, received during her hospitalization.

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