Crohn’s Disease Surgical Treatment

Maher A. Abbas, MD
Compassion, Excellence, Integrity

Diplomate, American Board of Surgery

Diplomate, American Board of Colon and Rectal Surgery

Fellow, American College of Surgeons

Fellow, American Society of Colon and Rectal Surgeons

“The best interest of the patient is the only interest to be considered…”W.J. Mayo, MD (Founder of the Mayo Clinic)

Dr. Maher Abbas is an American Board Certified Colon and Rectal Surgeon who performs the latest and most advanced procedures to treat conditions affecting the small intestine, colon, rectum, and anus.  He is a leader in minimally invasive and endoscopic surgery. With over 14,000 operations and procedures experience, he provides state of the art treatment to his patients.

What is Crohn’s disease?

Crohn’s disease is a condition which causes inflammation and ulceration of the intestine.  Different parts of the digestive tract can be affected including the small intestine, colon, rectum, and anus.  The most common areas affected are the last part of the small intestine (ileum) and the colon.  The inflammation leads to narrowing of the intestine with blockage and/or perforation (a hole in the bowel) with fistula formation and infection.  Some patients can develop inflammation of other parts of the body such as the bone joints, eyes, liver, and skin.  Crohn’s disease can be painful and debilitating and does require life-long treatment.

Nearly a hundred years after its original description, the cause of Crohn’s disease remains unknown.   Malfunction of the immune system and heredity factors play a factor.   It is unclear to what degree environmental exposure, diet, or infection trigger this condition.   Crohn’s disease can occur at any age but is often diagnosed in young people by the age of 30.   It can affect most ethnic groups and it can run in some families.  Smoking worsens the symptoms of Crohn’s disease.

 

What are the symptoms of Crohn’s disease?

Crohn’s disease may lead to one or more complications such as bowel obstruction, ulcers or open sores from mouth to anus, fistulas (abnormal connection between two different parts of body such as intestine to skin), and colon or small bowel cancer.  The symptoms and clinical findings of Crohn’s disease can vary from mild to severe and include one or more of the following:

  • Abdominal pain and cramping
  • Anemia
  • Blood in the stool
  • Delayed growth in children
  • Diarrhea
  • Eye inflammation
  • Fatigue
  • Fever
  • Inflammation of the liver and bile ducts
  • Joint inflammation
  • Lack of appetite and weight loss
  • Malnutrition, vitamin B12 deficiency
  • Mouth sores
  • Skin infection and abscess around anus with pus drainage
  • Ulcers in the anus

 

How is Crohn’s disease diagnosed?

Dr. Maher Abbas will assess your symptoms and perform a physical examination before recommending specific tests to either diagnose Crohn’s disease or to assess severity of inflammation.  Helpful tests include:

  • Blood tests: CBC (complete blood count to test for anemia or infection), CRP (C reactive protein) and ESR (erythrocyte sedimentation rate) to assess degree of inflammation, thyroid function tests, liver and kidney function tests, tests for hepatitis virus and tuberculosis

  • Imaging studies: computed tomography scan (CT) and/or magnetic resonance imaging (MRI) are special radiological studies to look inside the abdomen and pelvis. A variation of both scans is enterography which utilizes special techniques to look specifically at the small intestine.  Pelvic MRI can be helpful in patients with fistulas of the anus

  • Procedures: Gastroscopy and/or Colonoscopy which are procedures which allow Dr. Maher Abbas to look inside the stomach and colon. Capsule endoscopy is another type of test that entails swallowing a small camera capsule that travels to the small intestine and takes pictures

  • Stool tests: calprotectin level (to assess for degree of inflammation in the intestine), clostridium difficile bacteria toxin, FOBT (fecal occult blood test)

How is Crohn’s Disease treated?

Medical Treatment

 

There is no current cure for Crohn’s disease but there are several effective medical treatments that can reduce and control the symptoms.  It is essential that patients with Crohn’s disease work closely with a gastroenterologist and a colorectal surgeon to have the best outcome.  The objective of medical treatment is to control the inflammation and limit the patient’s symptoms.  In some patients, long-term remission (no symptoms) can be achieved.  Various types of medications are currently available to treat Crohn’s disease:

  • Antibiotics: are often used in Crohn’s disease, especially in patients with anal fistula and abscess. The 2 most frequently used antibiotics are metronidazole and ciprofloxacin

  • Anti-inflammatory medications: corticosteroids (prednisone and budesonide) and oral 5- aminosalicylates medications (sulfasalazine, mesalamine). Most of these medications are used as oral pills but in some cases maybe used in combination with anal suppositories or rectal enemas

  • Biologics: medications that target various aspects of the immune system. Several types are available and work by different mechanisms.   Infliximab, adalimumab, certolizumab work by neutralizing an immune system protein known as tumor necrosis factor (TNF).  Vedolizumab work by blocking immune cell molecules called integrins.  The latest addition is a new medication called ustekinumab which blocks special immune system proteins called interleukins

  • Immunosuppressive medications: such as azathioprine and mercaptopurine
  • Methotrexate: inhibits folic acid metabolism

It is important to consult with a gastroenterologist who specializes in and has special interest in the management of inflammatory bowel disease.  Care of patients with Crohn’s disease should always be coordinated with a colorectal surgeon, especially when patients need surgical procedures.

Other medications can be helpful including anti-diarrheal medications, pain relievers such as paracetamol or acetaminophen (best to avoid non-steroidal anti-inflammatory medications such as ibuprofen, naproxen, diclofenac sodium, as they can worsen the symptoms of Crohn’s disease).  Supplementation with iron, vitamin B12, vitamin D, calcium, and other multivitamins can be helpful.  For patients with poor nutrition, nutritional supplementation is available through oral liquid solutions or intravenous injection depending on ability of patients to take oral intake.  A referral to a dietician can provide an opportunity to customize a specific diet for the patient.  When there is narrowing of the bowel, in general eating several low residue small meals rather than 3 large meals is advisable.   Limiting fatty food, dairy products, spicy food, and alcohol during phases of active inflammation of the gut can be beneficial.  Maintaining a food diary can be helpful in determining which foods are easier to digest in an individual patient.  Stress reduction and smoking cessation should be considered as smoking increases the likelihood of relapse and the need for multiple surgeries.  Joining a support group or staying informed through online resources such as the Crohn’s & Colitis foundation.

Surgical Treatment

Medical treatment should be the first line of therapy in patients with Crohn’s disease except for hospitalized patients who present with a surgical emergency.  In most patients, surgery can be considered as a second line therapy to treat the complications of Crohn’s disease.  Surgical intervention can enhance the effectiveness of medical therapy.  The type of surgical procedures depends on which part of the digestive system is affected by Crohn’s disease.  The quality of the surgery, the judgment and expertise of the surgeon can make a huge difference for the patient.  Colorectal surgery is the specialty that deals with inflammatory bowel disease including Crohn’s disease.

The most common operations done for this condition involve procedures on the anus and rectum.  Drainage of abscess and control of anal fistula is often the first step followed by medical therapy and at a later phase closure of fistula. For patients with small intestine or colon involvement, removal of the inflamed segment is necessary. While there are various techniques available to treat patients, Laparoscopic Camera Surgery (keyhole surgery) is the preferred method of surgery. Camera surgery is associated with less pain, faster recovery, and fewer short and long-term complications compared to other techniques. In addition, endoscopic surgery (going through the anus without any cuts or scars on the abdomen) maybe an option for some patients with narrowing of the small intestine or colon.  Dr. Maher Abbas is an expert in minimally invasive techniques including Laparoscopic Camera Surgery and endoscopic surgery.

If you would like to schedule a consultation with Dr. Maher Abbas, click here. If you have previously undergone any testing, kindly bring all outside reports and imaging studies for Dr. Maher Abbas to review the day of your consultation.

 

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