Challenges in the Medical and Surgical Management of Chronic Inflammatory Bowel Disease

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Key points

  • Inflammatory bowel disease is often a chronic relapsing medical condition requiring a multidisciplinary team and thoughtful surgical approach for optimal outcomes.

  • Intestinal fistula is a devastating but well-recognized complication of Crohn's disease, and the management approach involves nutritional optimization, wound containment, and careful operative planning.

  • Crohn's disease after multiple resections or long segment involvement can result in short bowel syndrome, and the challenges of

Intestinal fistula

By definition, this process involves only those patients with Crohn's disease, because ulcerative colitis does not demonstrate transmural inflammation except in the acute setting when perforation is more likely than fistulization. An estimated 5% to 15% of Crohn patients will experience this disease-related complication during their lifetime.8 A fistula is a connection between 2 epithelialized surfaces and is commonly identified by the 2 involved organs (ie, enterocolonic or colovaginal).

Short bowel syndrome

Classically short bowel is defined by loss of absorptive surface to the degree that patients demonstrate dehydration and malnutrition necessitating supplementation for health maintenance. This complication is usually observed when less than 200 cm of small bowel remain proximal to a stoma or less than 100 cm of small bowel remain proximal to an enterocolostomy, although every patient responds differently, and long-term adaptations can lead to recovery of bowel function. A longer segment of

Pouch complications

For patients with a diagnosis of ulcerative colitis who desire restoration of intestinal continuity after proctocolectomy, the ileal pouch anal anastomosis (IPAA) is performed. This procedure was first described by Sir Alan Parks and Nicholls in 197842 and is now commonly offered to individuals with good sphincter function as an alternative to a permanent stoma. Despite a low mortality, there are several unique complications arising from this restorative proctocolectomy.

Pelvic sepsis results

Deep venous thrombosis

Individuals with inflammatory bowel disease exhibit increased rates of venous thromboembolic events (VTE) during hospitalizations and especially after intestinal resection.61 Sites of involvement range from extremity deep venous thrombosis to pulmonary embolism, mesenteric and portal venous thrombosis, and thromboembolic phenomena and can occasionally result in death. Patients can experience VTE despite appropriate mechanical and pharmacologic prophylaxis so the provider’s index of suspicion

Summary

Inflammatory bowel disease affects a significant portion of the American population and frequently follows a chronic clinical course with episodic flares and periods of remission. Many patients with Crohn's disease and ulcerative colitis will ultimately come to surgical resection, and these individuals require an organized operative approach tailored to their anatomy and distribution of disease. Presented are several specific complications with unique implications in the inflammatory bowel

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