Inflammatory Bowel Disease

IBD Basics - Tale of Two Guts

IBD: Chronic gut inflammation. Crohn's (CD) vs Ulcerative Colitis (UC).

📌 CD: Skip lesions, Transmural, Right side (ileum), Inflammation anywhere, No cure (surgery), Granulomas. (STRING) 📌 UC: Colon only, Limited depth, Abscesses (crypt), Pseudopolyps, Surgery curative. (CLAPS)

Crohn's Surgery - Patch & Proceed

• Core Principle: "Patch & Proceed" - address acute complications, conserve maximal bowel length.
• Indications:
  • Failure of maximal medical therapy
  • Complications:
    • Fibrotic strictures (obstruction)
    • Fistulae (enterocutaneous, enteroenteric, enterovesical)
    • Abscess (intra-abdominal, pelvic)
    • Perforation, massive hemorrhage, dysplasia/cancer
• Surgical Options:
  • Strictureplasty: For fibrotic strictures (e.g., Heineke-Mikulicz for <7cm, Finney for 10-15cm). Avoids resection.
  • Limited Resection: For diseased segment only (e.g., ileocecal resection). Side-to-side anastomosis preferred.
  • Drainage of abscesses, seton for complex fistulae.

⭐ Post-operative recurrence is common in Crohn's disease, often at the neoterminal ileum proximal to an anastomosis.

UC Surgery - Colon's Last Stand

• Indications for Surgery:
  • Failure of maximal medical therapy (MMT).
  • Dysplasia or colorectal cancer (CRC) on surveillance.
  • Acute severe colitis (e.g., toxic megacolon, perforation, massive hemorrhage) refractory to medical Rx.
  • Chronic, debilitating symptoms.
• Key Surgical Procedures:
  • Total Proctocolectomy (TPC) + End Ileostomy: Curative; removes colon & rectum. Permanent stoma.
  • Restorative Proctocolectomy + Ileal Pouch-Anal Anastomosis (IPAA / J-pouch): Preferred elective. Sphincter-sparing. Often 2-3 stages.
    • Complications: Pouchitis, cuffitis, anastomotic leak/stricture, ↓ female fertility.
  • Subtotal Colectomy + End Ileostomy & Rectal Stump: Emergency (acute severe colitis); allows future IPAA.

⭐ Pouchitis, inflammation of the ileal pouch, is the most common long-term complication after IPAA, affecting 15-50% of patients.

IBD Complications & Special Cases - Gut Wrenching Woes

• Post-Surgical Complications:
  • Anastomotic Leak: Early sign - sepsis. High mortality.
  • Pouchitis (post-IPAA for UC): Inflammation of ileal pouch. Rx: Antibiotics (metronidazole, ciprofloxacin).
  • Strictures: Anastomotic or de novo. Endoscopic dilatation or surgery.
• Stoma Management & Issues:
  • High-output stoma: >1.5L/day. Risk: Dehydration, electrolyte imbalance.
  • Complications: Retraction, prolapse, parastomal hernia, skin irritation.
• Specific Challenges:
  • Short Bowel Syndrome (SBS): <200cm of remaining small bowel. Leads to malabsorption.
  • Perianal Disease (Crohn's): Fistulas, abscesses, fissures. Often complex.
  • Nutritional Deficiencies: Common. Monitor Fe, B12, Vit D, Zinc.

⭐ Pouchitis is the most common long-term complication after Ileal Pouch-Anal Anastomosis (IPAA) for Ulcerative Colitis, occurring in up to 50% of patients within 10 years post-surgery.

High‑Yield Points - ⚡ Biggest Takeaways

• Crohn's Disease (CD): Surgery for complications (strictures, fistulae); strictureplasty is bowel-sparing. Anastomotic recurrence is high.
• Ulcerative Colitis (UC): Total Proctocolectomy with Ileal Pouch-Anal Anastomosis (IPAA) is curative. Toxic megacolon needs emergency colectomy.
• Cancer risk (CRC) elevated in long-standing colitis, especially UC, necessitating surveillance.
• Skip lesions and transmural inflammation characterize CD; continuous mucosal inflammation for UC.
• IPAA is generally contraindicated in CD due to high risk of pouchitis, fistula, and failure.
• Perianal disease (fistulae, abscesses) is a common and challenging manifestation of CD.
• Medical management is primary; surgery for failed medical therapy or complications like obstruction, perforation, or uncontrolled bleeding in both CD and UC.