Controversies in Crohn's disease

Despite recent advances in the medical therapy of Crohn's disease, surgery continues to play a central role in the treatment of the disease. The strategy for surgical management of Crohn's disease continues to evolve. This chapter reviews many of the controversies surrounding surgical palliation of complications of Crohn's disease. Included is a discussion of indications for strictureplasty in treatment of intractable intestinal obstruction. Factors influencing long-term outcome with sphincter-saving resection in the treatment of Crohn's colitis are reviewed. Experience with definitive treatment of anal Crohn's disease and repair of rectovaginal fistulas is examined. Finally, recent experience supporting ileocolic resection when acute Crohn's ileitis is identified during laparotomy for right lower quadrant pain is critically evaluated. These controversial aspects of the surgical treatment of Crohn's disease reflect an improved understanding of the natural history of the disease as well as refinement in surgical techniques and better definition of criteria for surgical intervention.     

Crohn's disease in children

Crohn's disease is a chronic inflammatory condition that may affect any part of the gastrointestinal system and multiple extraintestinal organs. Although its exact pathogenesis remains unknown, increasing evidence suggests an abnormality in the control of "physiologic" inflammation caused by bacterial and other antigens. Diagnosis starts with a careful history and physical examination, and confirmation rests with radiologic and histologic studies. Newer treatments are more specifically targeting the cascade of cytokine-mediated events that perpetuate inflammation.     

Crohn's disease in the elderly

Primary Crohn's disease in the elderly is a not frequent pathology, which however have distinguished from the reheightening or relapse of an inflammatory illness risen up in juvenile age. The Authors compare the personal experience (6 cases on 120 patients operated for Crohn's disease) with the data of the literature. The more frequent localization stays the ileo-colic one, also if in the elderly present better impact the cases of Crohn's colitis (pancolitis or left colitis), with frequent and- perianal implications. The symptomatology is not pathognomonic and above all in the cases of colitis sets problems of differential diagnosis with other pathologies, among which the diverticular disease, that on the other hand, can also coexist with the inflammatory illness. A pharmacological treatment is desiderable, but frequently doesn't result effective. The surgical conservative therapy is not always possible and could be necessary resort to maiming interventions, like massive ileal resections or a total proctocolectomy. From the prognostic point of view, the course appears from the beginning or very favorable (with low index of relapse) or tumultuous (with acute manifestations, which require an emergency surgery, wighted by a more elevated rates of mortality and morbidity.     

Cerebral infarction in Crohn's disease

Thromboembolic complications in Crohn's disease are not rare. Most of them are disseminated vascular thrombosis or pulmonary emboli. Cerebral artery thrombosis is a rare complication of Crohn's disease. We describe a 27-year-old woman who had Crohn's disease for 8 years, with exacerbation 3 months before admission. She had bloody diarrhea, abdominal pain, weight loss, weakness, and anemia. Hemoglobin was 6.3 g/dl and she received 3 packed cell transfusions the day of admission. Her hemoglobin level rose to 13 g/dl. 2 days after admission she had generalized tonic-clonic convulsions, followed by hemiparesis. EEG and CT examinations showed right temporal lobe infarction. Many studies report a hypercoagulable state in Crohn's disease, which results in a thromboembolic tendency that is potentially fatal.     

Postoperative recurrence in Crohn's disease

Intestinal resection in the natural history of Crohn's disease is a forced step. Unfortunately surgery is not curative as disease inexorably recurs. The frequency of recurrence varies according to the definitions adopted, being high when endoscopical criteria are used (70-90% at one year). Among risk factors, the most convincing is a smoking habit. The pathogenesis of recurrence is still unknown. Particular attention was paid to colo-ileal reflux which occurs after the resection of the ileocecal valve. The diagnosis should always be based on morphological criteria (endoscopy or radiology). In fact symptoms occur late and are often uncharacteristic. A particular problem in the management of patients with Crohn's disease is the prevention of post-operative recurrence. Recent randomized, controlled trials of which the first has been published by the authors of this article, demonstrated that the administration of 5-ASA early after resection may prevent, delay or attenuate such recurrences. Cessation of smoking also plays a central role in prevention. The final message is that in active Crohn's disease surgery should not be excessively delayed. Early resection followed by prophylactic treatment seems to improve the quality of life in patients with more severe Crohn's disease.     

Laparoscopic surgery in Crohn's disease

In a prospective study the feasibility and safety of laparoscopic-assisted ileocaecal resection for Crohn's disease was studied and compared with 16 patients who had open ileocaecal resection, and the value of laparoscopic stoma surgery was assessed. From January to November 1995 laparoscopic-assisted ileocaecal resection for Crohn's disease was undertaken in 7 patients, laparoscopic-assisted stoma formation in 10 patients. In 1 patient laparoscopic ileocaecal resection was converted to open surgery due to an unrecognised ileocolic fistula. Operating time in laparoscopic-assisted ileocaecal resections was longer than in open ileocaecal resection (150 vs. 127 min, P = 0.7). Blood loss (386 vs. 445 ml, P = 0.7), first bowel movement (3.5 vs. 4.9 postoperative days, P = 0.07) and postoperative time to discharge (5.2 vs. 9.9 days, P < 0.01) in patients who had a laparoscopic-assisted ileocaecal resection were less than in patients who had open surgery. In all 10 patients laparoscopic formation of a stoma was possible. Operating time was 62 min. Oral solids were restored on the 1.5 postoperative day. Mean postoperative stay was 8.8 days, prolonged due to time needed for stoma-care training. These preliminary results indicate that laparoscopic-assisted ileocaecal resection and stoma surgery for Crohn's disease are feasible and safe. Both procedures are characterised by rapid recovery and superior cosmetic results.     

Ileocolic linitis in Crohn's disease

Intestinal cancer is uncommon in Crohn's disease but the risk of developing such a tumor is increased. Linitis plastica of the small bowel or colon is very rare. We report a case of ileocolonic linitis plastica which occurred 21 years after an ileocecal resection for Crohn's disease. Partial small bowel obstruction in relation with stricture of the preanastomotic loop prompted us to suspect disease recurrence. The tumor was not diagnosed either on preoperative work-up, or during surgery but only on the histological examination of the resected specimen. Palliative chemotherapy with 5 FU and folinic acid was performed. The patient was asymptomatic after a 17-month follow-up. This observation focuses on the clinical signs and course of linitis plastica. It also illustrates the difficulty of tumor diagnosis in Crohn's disease. Malignant transformation must be suspected if signs of active disease re-occur after a lengthy quiescent period.     

Colonic-duodenal fistula in Crohn's disease

A fistula between the ascending colon and the duodenum occurs not uncommonly as a complication of Crohn's disease with primarily colonic involvement. Clinical and radiological findings in four cases are presented. In three instances the fistula served as an indication for surgical intervention; after ileosigmoidostomy, ileorectal anastomosis, and ileostomy alone, the patients improved clinically but x-ray evidence of patency of the fistula persisted. Recurrent activity of the Crohn's disease in two responded to medical treatment as it did in one patient without surgery at all. The internal fistula need not be a seriuos complication of Crohn's disease and should not serve as an indication for surgical correction for its own sake.     

The dilemma of Crohn's disease: ileosigmoidal fistula complicating Crohn's disease

Between 1965 and 1975, 27 patients underwent surgical treatment for ileosigmoidal fistulas complicating Crohn's disease at the Cleveland Clinic. There was no death and no anastomotic leak. The preferred procedure is resection of the ileocecal area involved by Crohn's disease with ileocolic anastomosis and a separate segmental resection of the sigmoid colon with colocolic anastomosis. A covering temporary loop ileostomy is used when there is associated pelvic sepsis or small-bowel obstruction.     

Regional ileitis (Crohn's disease). I. Kinetics of bile acid absorption in the perfused ileum

Bile acid absorption was studied by steady state perfusion technique in the ileum of 11 patients with regional ileitis (Crohn's disease). By computerizing absorption kinetics the presence of an active transport of glycochenodeoxycholic acid (GCDC) was rendered probable by finding a saturable transport system and a competitive absorption between conjugated bile acids. At the time of investigation 5 patients had no diarrhoea, whereas 6 patients had diarrhoea as defined from the amount of faecal output. In the former group the faecal bile acid excretion was low, the ileal absorption of GCDC high, and judged from the xylose absorption the ileal absorption surface large compared to the latter group, in which the faecal bile acid excretion was high, the ileal absorption of GCDC low, and the ileal absorptive surface small. It is concluded that malabsorption of bile acids in the ileum may be of significant physiological importance in the pathogenesis of diarrhoea in patients with regional ileitis.     

Therapy of Crohn's disease in childhood

The aim of therapy in Crohn's disease in childhood is to induce and to maintain a remission of disease activity so that normal growth and development of the child may occur. Enteral nutrition may now be recommended as the first-line treatment for most children with Crohn's disease. However, the evidence for remission is better for children with Crohn's disease of the small intestine rather than of the large intestine. There is evidence that amino acid feeds (elemental), whole protein (polymeric) and protein hydrolysate feeds (semi-elemental) may all be successful. Such a therapeutic approach can lead to healing of the mucosa and down-regulation of inflammation. However, in some cases surgery is required, particularly in children with growth failure and delayed puberty. Drug therapy also continues to have a role in therapy especially with severe colonic disease.     

Colonic involvement in ileal Crohn's disease

OBJECTIVES: To determine the risk and predictive factors for colonic extension in patients with ileal Crohn's disease. METHODS: One hundred and fifty patients with ileal Crohn's disease and no specific colonic lesions on initial colonoscopy were studied retrospectively (median follow-up: 51 months). RESULTS: Twelve patients (8%) developed colonic lesions. Ten-year cumulated risks (95% confidence interval) for colonic extension were 17.2% (range: 5.8-28.6) in the whole group, and 22.4% (range: 8.7-36.1) in the group of 86 patients with repeated colonoscopy. Young age at diagnosis was the only factor predicting colonic extension. Seven patients with colonic extension required immunosuppressive therapy but none underwent surgery. CONCLUSION: Ileal Crohn's disease has a low tendency for colonic extension. Colonic extension has no major prognostic implications.     

Laparoscopy for Crohn's disease in children

Traditionally, the diagnosis of Crohn's disease is established by colonoileoscopy and radiology. With these techniques the main area of interest, the distal ileum, is not easily reached. Also, the outer aspect of the bowel is ignored and there is no appreciation of the involvement of other intra-abdominal organs. Laparoscopy provides additional information. This may establish a more precise diagnosis, better standardization in comparative studies, and more specific therapy.