Bimodal distribution

Smoking is a risk factor

More common in high socioeconomic areas

Aphthous ulcers! Mucosal ulcers

Cobblestone mucosa

Deep longitudinal ulcers

TPN, flagyl and infliximab can close fistulas.

• Infliximab (monoclonal chimeric Ab to TNF) - moderately active crohns, treats persistent perianal fistulas that have failed abx and surgical management

Crohn’s disease is a significant risk factor to developing cholelithiasis. UNLIKE UC.

All IBD causes a hypercoagulable state

Growth retardation is an indication for surgery

Unable to wean off or side effects from steroids is an indication for surgery

Vit A → stimulation of fibroplasia, collagen cross-linking, epithelialization

• Reverse inhibitory effects of glucocorticoids on the inflammatory phase of wound healing
• Give Vit A for pts on chronic steroids

Perforation with Crohn’s → MC ileum.

Terminal ileum resection for Crohn’s leads to: kidney stones, megaloblastic anemia, steatorrhea, and gallstones

Treatment of mild active disease:

• IV steroids are the best treatment for an acute Crohn’s disease exacerbation
  • Methylprednisolone 60 mg
• Sulfasalazine
• Mesalamine  Does not work on ileum!!! Don’t use for small bowel Crohn’s. Used mostly for UC. It has fewer side effects but is activated by colonic bacteria
• Infliximab (monoclonal chimeric Ab to TNF) - moderately active crohns, treats persistent perianal fistulas that have failed abx and surgical management

Surgical principles:

• Before operating: try to obtain enterography CT/MRI

• When operating due to complications of Crohn’s disease, you should ALWAYS try to avoid operating during an acute flare, unless it is emergent

• If patient with Crohn’s has abdominal abscess place drain, try to wait out inflammatory period before operating

• If operating in distal ileum due to stricture/perf/etc. the operation will be ileocectomy. Take the cecum

• If on Biologics or 5-ASA can continue them perioperatively

  • 5-ASA works directly on the bowel lining
  • Anti-TNF agents have not been shown to increase post-op complications, including wound healing

• Chronic steroids will increase the risk of post-operative abdominal complications

  • Greater incidence of infection related complications

• Thiopurines (Azathioprine) use 6 weeks prior to operation had increased risk of post-op morbidity → anastomotic leaks, sepsis

• Perianal, rectovesicular, rectovaginal fistula

  • Tx: Bowel rest, flagyl and infliximab is 1st line
    • Fistulizing disease responds well to anti-cytokine treatment with anti-TNF drugs

• Crohn’s perforation, refractory toxic colitis, pancolitis with dysplasia → total abdominal colectomy

• Resection margins = 2 cm grossly visible disease. Don’t worry about microscopic dz. No difference between disease-free margin at 1-2 cm.

  • Microscopic inflammation in resection margin independently predicts short-term intra-abdominal septic complications s/p ileocolic resection and primary anastomosis

• No difference in cumulative risk of post-op complications in 30 days s/p surgery compared to pts undergoing 1 stage vs 2 stage procedure

• Randomized controlled trial (139 pt) showed no difference in overall complication rates, anastomosis-associated complications, or re-operation rates between stapled side-to-side vs hand sewn

• Crohn’s stricture in the 1st or 2nd portion of duodenum → tx with gastrojejunostomy with highly selective vagotomy. Do a vagotomy BC these patients were found to have marginal ulcers

• Crohn’s stricture in the 3rd or 4th portion of duodenum duodenojejunostomy

• No whipple for duodenal Crohn’s

• Obstruction/Stricture

  • Tx: segmental resection
  • Alt: side-to-side stricturoplasty (best suited for pts with multiple short, localized areas of chronic stenosis, increased risk of short bowel syndrome 2/2 previous intestinal resection)

• Retrospective study showed enteral nutrition 3 months pre-op resulted in significantly lower rate of intra-abdominal septic complications. Shows enteral nutrition is viable alternative to parenteral nutrition

Infliximab – used if active disease refractory to prednisone OR to keep patients in remission

Increases risk of TB, multiple sclerosis, lymphoma and aspergillus infxn.

Crohn’s perianal fistula → Infliximab, flagyl and seton

Fissure – no lateral internal sphincteroplasty

Hemorrhoids – no resection