1. Which two types of infectious bowel diseases are clinically prevalent? Crohn’s disease and ulcerative colitis, which can be acute or chronic.
Although there is often overlap between these two diseases, they can usually be distinguished clinically, by imaging and pathology. What are the main clinical differences?
Rectal bleeding is uncommon in Crohn’s disease but is common in chronic ulcerative colitis. Abdominal masses and anal canal complications (anal fissures, fistulas) are more common in Crohn’s disease.
3. What are the significant differences in imaging?
Crohn’s disease commonly involves the distal ileum with jumping areas, internal fistulas, and fingerprints, whereas these signs are rare or absent in chronic ulcerative colitis.
4. What are the major morphologic differences?
In Crohn’s disease, granulomas and peri-colonic lymph nodes are seen in 60% of cases, whereas in chronic ulcerative colitis, there are no such changes.
5. Given that Crohn’s disease has been shown to affect the entire gastrointestinal tract from the pharynx to the anal canal, what is the most common type of gastrointestinal involvement?
The small intestine type is 28%, the ileocolic type (ileocolitis) is 41%, and the simple colon type is 27%. The latter has several names, such as Crohn’s colitis, granulomatous colitis.
6. Crohn’s colitis is often clinically indistinguishable from ulcerative colitis. What are the significant differences that physicians can detect from colonoscopy?
Crohn’s disease presents as a restrictive lesion, predominantly in the right hemicolon. The mucosa in the affected area shows cobblestone changes with ulcers crossing the surface. Biopsy findings suggest localized granulomas with penetrating changes. Chronic ulcerative colitis colonoscopically appears as a diffuse lesion. However, if only a portion of the colon is involved, the lesion is located in the left hemicolectum and almost always involves the rectum. Pathological changes mainly involve the mucosa and submucosa.
7.What is the main indication for surgery in Crohn’s disease?
The indication for surgery depends on the site of involvement. Entero-enteric fistulas (debated), abscesses and intestinal obstruction are the most common indications for the small bowel and ileocolic types. Failure of medication for perianal disease and abscess formation of ileocolic fistula are the most common surgical indications for the colonic type.
8. What are the indications for surgery for chronic ulcerative colitis?
Difficult to control by drugs (including non-growth, diarrhea, weight loss and abdominal pain in children), toxic megacolon with or without perforation, and concern about the development of colon cancer (controversial) are the main
9.What are the surgical measures to treat ulcerative colitis?
Total colectomy with ileoanal pouch anastomosis is the recently accepted standard procedure. The standard Brooke’s ileostomy or Kock pouch approach can be used in special cases. Ileorectal anastomosis is embraced by some physicians (controversial).
10. What are the acceptable procedures to treat complications of Crohn’s disease?
Complications requiring surgical treatment usually require resection of the entire area involved by the complication. Some experience has been gained (controversially) with stenosis sutures (longitudinal and transverse sutures) versus resection in some selected patients with small bowel obstruction. When resection is mandatory, total clear boundaries are to be satisfactory. The jumping area should be preserved, except for those directly adjacent to the resected bowel segment.
11.How should the patient be informed about the recurrence of infectious bowel disease after surgery?
The effect of surgical treatment of chronic ulcerative colitis is obvious and certain. The purpose of surgery for Crohn’s disease is to treat complications, such as obstruction, sepsis, etc. If after a long period of
It is controversial whether small bowel recurrence occurs after total colectomy for Crohn’s colitis.
Controversy
12. All patients with entero-enteric fistulas secondary to Crohn’s disease should be surgically supported after fistula discovery: these patients are in poor general condition, can develop further intra-abdominal sepsis, and usually eventually require surgical treatment.
Against: studies have shown that many patients with entero-enteric fistulas are asymptomatic without surgery.
13. All patients with proven chronic ulcerative colitis with an onset of 10 to 15 years or more, whether active or not, should undergo colectomy to avoid the risk of colon cancer
Support: The chance of developing colon cancer is 3% to 5%, which is 10 to 15 times higher than that of the general population. In addition, when diagnosed the cancer tends to be multifocal and is mostly progressive.
Objection: The application of biopsy techniques is necessary only for patients with atypical hyperplasia in the quiescent phase of the disease.
14. Ileorectal anastomosis after colectomy for ulcerative colitis is an acceptable procedure
Support: Patients are justified in having normal bowel habits and avoiding the problems and complications associated with other procedures.
Against: At least 50% of patients require reoperation due to recurrence of the lesion. Moreover, the preserved rectum is the site of cancer development.
15. Is a standard ileostomy (Brook) a good way to control the terminal ileum after total colectomy for chronic ulcerative colitis?
Support: Complications are very rare and more than 90% of the studied patients have a very satisfactory quality of life.
Against: There are definite psycho-social-sexual problems with stoma. These are particularly prominent in teenage patients, while chronic ulcerative colitis is very common in this age group.
16. Is KOCk pouch a good method after colonic resection for chronic ulcerative colitis?
Support: This method avoids the application of a stoma device and is fairly easy to manage.
Against: Approximately 20% to 30% of all patients with Kock pouches require revision surgery due to mechanical slippage of the flap causing pouch incontinence.
17. Is ileoanal anastomosis after colectomy for chronic ulcerative colitis a good procedure?
Support: This procedure allows the patient to avoid an external device and fistula, which is certainly very acceptable to the patient. It is perhaps the most common procedure used today after colectomy.
Against: It is a difficult reconstructive procedure and, as such, has an increased rate of complications. The average number of bowel movements during the day is 4 to 6 per day, and contamination may also occur at night.
18. Is stenosis suture an acceptable procedure for Crohn’s disease secondary to fibrous stenosis causing small bowel obstruction?
Support: This procedure preserves the maximum length of diseased small bowel that is prone to recurrence.
Oppose: The surgical mortality may be increased and restenosis may occur at the location of the stenosis suture.