Q27. Write a note on ulcerative colitis.
Discuss the features and management of Crohn’s disease.
Differentiate between Ulcerative colitis and Crohn’s disease.
Ans.
Ulcerative colitis Crohn’s disease
Both have equal incidence in males and females Both are more common in women who use OC pills
Both are equally premalignant and predispose to carcinoma colon Have strong familial association
Risk factors
Smoking and appendectomy are protective Smoking predisposes
Infections – C.difficile, C.jejuni M. paratuberculosis, Measles virus
Ch. 12q – IBD-2 locus Ch.16q- IBD1 locus
pANCA positive ASCA positive
Pathology
Continuous involvement Skip lesions
Only large bowel involved with/out backwash
ileitis Mouth to anus with relative rectal sparing
Earliest finding is blurring of mucosal stripe
and granular appearance Earliest lesion – superficial aphthous ulcer Mucosa and submucosa involved Transmural involvement
Commonly rectum Commonly ileum and ascending colon
Fibroses rare Fibroses common
Crypt abscess, crypt branching seen Noncaseating granulomas common
Submucosa is narrowed Submucosa is widened
Contd...
Ulcerative colitis Crohn’s disease Clinical features
Diarrhea is more frequent and more severe Less common Commonly contain mucus, pus or blood Less common Complications
Stricture less common, +nce suggests
malignancy. Stricture more common
Toxic megacolon occurs Rarely occurs
Fistulas are extremely rare Very common
Malignant change can occur Malignant change can occur.
Extra-intestinal manifestations
m.c. manifestation in both is erythema nodosum. It is most responsive to treatment of IBD.
Persistence of it suggests inadequate treatment Ulcerative colitis is more commonly associated with the extra-intestinal manifestations Pyoderma gangrenosum is more common.
Primary sclerosing cholangitis is also more common with UC.
Erythema nodosum, peripheral arthritis, cholelithiases, renal stones, ankylosing spondylitis are more common.
Common radiological appearance
Garden hose appearance Hose pipe appearance
Pseudopolyps Cobblestone appearance
Pipestem colon String sign of kantor
Raspberry/rosethorn appearance Halo sign on CT
Surgery
Surgery is curative Surgery is curative
Ileal pouch can be constructed Ileal pouch is associated with many complications and therefore not constructed Recurrence is less common Recurrences are very common
Medical management of IBD
Done in two phases – Induction phase and remission phase
y 5-ASA derivatives are used in induction phase. These include sulfasalazine, balsalazine, olsalazine and mesalamine.
y Steroids can also be used for induction of remission.
y In maintenance phase, azathioprine or 6-mercaptopurine is preferred.
y Infliximab is useful mainly in fistulizing Crohn’s.
Indications of surgery y Intractability y Dysplasia/carcinoma y Toxic megacolon
Contd...
Surgeries
y Total proctocolectomy with ileal-pouch-anal anastamosis – Gold standard elective procedure
– 2 Techniques
- IPAA and anal mucosectomy with hand sewn anastamosis - IPAA with double stapled anastamosis
y Open or laparoscopic total proctocolectomy with End-ileostomy – Indications
- Elderly
- Incontinent patients
y Colectomy with hartmann’s closure of rectum or mucous fistula – Indications
- Acutely ill patient (fulminant colitis or toxic megacolon) - Pre-operative difficulty differentiating between UC and Crohn’s
Q28. Enumerate the causes of lower GI bleeding and discuss its management in brief.
Ans.
(Imp : always remember : GI bleed terminology y Hemetemesis – vomiting of blood (upper GI bleed)
y Melena – black, tarry, sticky, foul smelling stools in patients with bleeding of atleast 60 ml blood from a site above the ligament of treitz and transit time of at least 14 hours y Hematochezia – bright red blood in stool.
y Rectorrhagia/bleeding PR – only blood per rectum without stool.) Lower GI bleed
Bleeding below the ligament of treitz Causes
Colonic (95%) Small intestinal (5%)
Diverticular disease (m.c.) Angiodysplasia
Anorectal disease Erosions/ulcers (enteric, TB)
Ischemic colitis, radiation colitis Radiation enteritis
Neoplasm/colitis Meckel’s diverticulum
Inflammatory bowel disease Post polypectomy
Always remember to rule out upper GI bleed as it is the most common cause of lower GI bleed
y m.c. cause of scanty lower GI bleed—Hemorrhoid
y m.c. cause of significant lower GI bleed—Diverticular disease y m.c. cause of significant small bowel bleed—Angiodysplasia
y m.c. cause of scanty, recurrent, obscure lower GI bleed—Angiodysplasia (vascular ectasia).
Management
If the patient is unstable, then proceed directly to surgery after resuscitation or perform damage control surgery as a part of resuscitation.
In such cases, if patient gives time, perform on table enteroscopy to identify the site of bleed. If still the site of bleed is not identified, proceed to serial clamping and resection or right hemicolectomy first. If still bleeding, then there is no option but to perform a total colectomy.
Direct performance of total colectomy without above mentioned steps is no longer considered rational.
For stable patients, manage according to the following steps:
Step 1 - Resuscitation
Fluid balance, electrolyte management and correction of acid-base balance once the fluid balance is taken care of are the life saving measures before surgery.
y Nasogastric tube placement for ruling out upper GI bleeding
y Send blood for coagulation parameters and platelets to rule out bleeding diathesis y Monitoring of urine output, intake of fluids, pulse, blood pressure, temperature and
respiratory rate is very important during this phase of resuscitation
y If necessary, a central venous line can be inserted to give fluid as per central venous pressure measurement
y Always send blood for cross matching and blood grouping to have blood available for transfusion during resuscitation or surgery
y Antibiotics are to be given if the patient is in sepsis or if he is planned for operation.
Step 2 – Colonoscopy V/S Tagged RBC scan (technetium labelled RBC scan)
y Tagged RBC scan is the most sensitive (can detect even 0.1 ml/min bleed) investigation to identify the presence of lower GI bleed and is to be done whenever patient has major active bleeding but is stable. It is of no use once bleeding has stopped. Also it has very poor ability to spatially localize the site of bleed
y Option to tagged RBC scan is mesenteric angiography which is also highly sensitive (can detect ongoing bleed of 0.5 ml/min). It has benefit of being able to carry out interventions at the same time as diagnoses such as intra- arterial vasopressin infusion or embolization of the bleeding site
y Minor bleeding or bleeding which has stopped cannot be picked up by tagged scan and in these cases, colonoscopy is to be performed
– If the site is not identified but the patient stops bleeding, repeat these investigations if patient rebleeds
– If the site is identified, then angiography and embolization or endoscopic management or surgical management can be done as per the cause of the bleed – If the colonoscopy and/or tagged scan are negative and the patient is still bleeding
proceed to next series of investigations (Step 3).
Step 3 – identification of bleed site in small bowel
Small bowel series/enteroclysis/capsule endoscopy/enteroscopy are to be used to identify the site of bleed in the small bowel. These are all the necessary tests and management measures to manage a patient with lower GI bleed.
Indications of surgery in case of gastrointestinal bleeding (Both UGI and LGI bleed) y Hemodynamic instability despite vigorous resuscitation (> 6 units transfusion) y Failure of endoscopic techniques to stop bleeding
y Third recurrence after endoscopic control of bleeding
y Continued slow bleeding with transfusion requirement exceeding 3 units/day y Shock associated with recurrent hemorrhage
Q29. What is sigmoid volvulus? Discuss its management.
Write a note on sigmoid volvulus.
Ans.
Definition
The condition in which the bowel becomes twisted on its mesenteric axis, a situation that results in partial or complete obstruction of the bowel lumen and a variable degree of impairment of its blood supply.
Etiology
y A long and floppy mesentery that is fixed to the retroperitoneum by a narrow base of origin
y Chronic constipation
y Aging (Seventh to eighth decade of life)
y Increased incidence of the condition in institutionalized patients afflicted with neuropsychiatric conditions and treated with psychotropic drugs. These medications may predispose to volvulus by affecting intestinal motility
y Diet high in fiber and vegetables
y Site - Sigmoid colon (m.c.) > The right colon and terminal ileum (cecal volvulus) > The cecum alone (cecal bascule) > transverse colon.
Clinical features
y Present as acute or subacute intestinal obstruction (describe characteristic features) y Severe abdominal pain, rebound tenderness, and tachycardia are ominous signs and
suggest ischemia.
Imaging characteristics
y Abdominal X-rays—Bent inner tube or coffee bean appearance
y An air-fluid level may be seen in the dilated loop of colon and gas is usually absent from the rectum
y CT—a characteristic mesenteric whorl is seen
y A contrast enema—Bird’s beak deformity, ace of spades or bird of prey deformity.
Management y Resuscitation
y Patients with signs of colonic necrosis should directly undergo surgery
y Nonoperative decompression (Achieved by placement of a rectal tube through a rigid proctoscope, but more often a flexible sigmoidoscope is used)
y The reduction should be confirmed with an abdominal radiograph
y The rectal tube should be taped to the thigh and left in place for 1 or 2 days to allow continued decompression and prevent immediate recurrence of the volvulus
y If detorsion of the volvulus cannot be accomplished with a rectal tube or flexible sigmoidoscope and in patients with peritonitis, laparotomy with resection of the sigmoid colon Hartmann’s operation or resection with primary anastomosis, with or without protection from a proximal ostomy (transverse colostomy or ileostomy) is required y Colonoscopy should be performed before elective resection to exclude an associated
neoplasm
y Elective sigmoid resection (resection with primary anastomosis) is indicated even in patients with successful detorsion because of a prohibitive rate of recurrence after detorsion alone.
Q30. Write a note on diverticulitis (Peridiverticulitis).
Ans.
y A misnomer as it is actually a perforation of a colonic diverticulum which leads to extraluminal pericolic infection due to the extravasation of feces.
y m.c. site - Sigmoid colon Clinical features
y Left lower quadrant abdominal pain that my radiate to the suprapubic area, left groin, or back
y Alterations in bowel habits y Fever, chills, and urinary urgency y Rectal bleeding is not usually associated
y Tenderness of the left lower abdomen, voluntary guarding of the left abdominal musculature and a tender mass in the left lower abdomen is suggestive of a phlegmon or abscess
y Abdominal wall distention if there is associated ileus or small bowel obstruction secondary to the inflammatory process
y A rectal or vaginal examination may reveal a tender fluctuant mass typical of a pelvic abscess.
Diagnoses
y Diagnosis based on careful history and physical examination - Begin treatment with antibiotics.
In case of doubt following diagnostic tests should be carried out:
y Computed tomography (CT) of the abdomen - reliably reveals the location of the infection, extent of the inflammatory process, presence and location of an abscess, and sympathetic involvement of other organs with secondary complications such as ureteral obstruction or a fistula to the bladder. In addition, an abscess detected by CT may often be drained by a percutaneous approach with the aid of CT guidance
y Magnetic resonance imaging (MRI) y Water-soluble contrast enema.
Hinchey’s classification
y Stage I: Pericolic or mesenteric abscess
y Stage II: Walled-off pelvic abscess y Stage III: Generalized purulent peritonitis y Stage IV: Generalized fecal peritonitis Management
Uncomplicated Diverticulitis 1st episode (Disease not associated with free intraperitoneal perforation, fistula formation, or obstruction)
y Antibiotics oral or IV antibiotics
y Marked improvement in symptoms within 48 hours
y After the symptoms have subsided for at least 3 weeks, colonoscopy should be conducted to establish the presence of diverticula and to exclude cancer, which can mimic diverticulitis
y High fiber diet should be started.
Recurrent attacks of diverticulitis (>2 attacks) - surgical treatment except in immuno- compromised patients where second attack itself is an indication for surgery.
Complicated diverticulitis y Abscess
– Drain by a percutaneous route guided by CT or ultrasound or transrectal approach – IV antibiotics
– Elective surgery approximately 6 weeks after drainage of the abscess.
y Generalized peritonitis
– Hartmann’s operation – resection and proximal taken out as stoma and distal closed and left inside
– IV antibiotics
– Appropriate generalized and nutritional support
– Restoration of intestinal continuity to be done after minimum 10 weeks.
y Fistula (Diverticulitis is a more common cause of a fistula between the colon and bladder than Crohn’s disease or cancer).
– Antibiotics – Rule out cancer
– A one-stage operation, taking down the fistula and excising the sigmoid colon and then fashioning an anastomosis between the descending colon and rectum.
y Obstruction
– Pass a nasogastric tube to relieve the upper intestinal secretions – Antibiotics
– Percutaneous drainage of the abscess.
Q31. Write a note on Hirschsprung’s disease (congenital megacolon).
Enumerate the causes of megacolon. Discuss Hirschsprung’s disease.
Ans. Megacolon is term used when the maximum diameter of colon exceeds a set value y Cecum - >12 cm
y Ascending colon - > 8 cm y Transverse colon - > 5.5 cm
y Rectosigmoid or descending colon - > 6.5 cm.
Causes of megacolon
y Acute Megacolon – same as pseudo-obstruction
y Chronic megacolon – neurologic, metabolic and systemic diseases Congenital – Hirschsprung’s disease
Acquired nontoxic megacolon – Chagas disease, Parkinson’s disease y Toxic megacolon
– Ulcerative colitis, Crohn’s colitis, Pseudomembranous colitis
– Drugs—Narcotics (Morphene, codeine), anticholinergics (scopolamine, atropine), antipsychotics (risperidone)
Hirschsprung’s disease
y Incidence : 1 in 5000 live births
y Boys affected four times more frequently than girls.
Pathogenesis
y Absence of ganglion cells in the myenteric (Auerbach) and submucosal (Meissner) plexus y The abnormal bowel is the contracted distal segment, whereas the normal bowel is the
proximal dilated portion y Down syndrome
y Family history (chromosome 10 - RET oncogene)
y Most common site is the rectosigmoid (80%) > splenic or transverse colon > entire colon.
Clinical presentation
y Failure to pass meconium within the first 24 hours of life y Progressive abdominal distention
y Bilious vomiting
y Diarrhea, fever, hematochezia and peritonitis suggest development of necrotizing enterocolitis
y Older age, poor feeding, chronic abdominal distention and significant constipation are seen.
Diagnosis
y Barium enema.
– Failure to evacuate the instilled contrast completely after 24 hours would also be indicative of Hirschsprung’s disease.
y Manometry – loss of rectoanal inhibitory reflex is seen.
y Rectal biopsy – Gold standard
– Obtain the sample at least 2 cm above the dentate line.
– Absent ganglia, hypertrophia nerve trunks, immunostaining for acetylcholinesterase (AChE), loss of calretinin immunostaining are the criteria to look for.
Surgical management
y Duhamel procedure - The aganglionic rectal stump is left in place and the ganglionated normal colon is pulled behind the stump
y Swenson procedure - The aganglionic bowel is removed down to the level of the internal sphincters and a coloanal anastomosis is performed
y Soave technique involves an endorectal mucosal dissection within the aganglionic distal rectum. The normally ganglionated colon is then pulled through the remnant muscular cuff and a coloanal anastomosis is performed
y Postoperative complications include constipation (m.c.), soiling, incontinence and enterocolitis.
Q32. What are the different types of stomas that are used in surgery? Enumerate the indications for bowel stomas.
Ans. Stoma can be of following types
y Urostomy—for draining of urine in case of radical cystectomy y GI stomas—Jejunostomy, ileostomy, colostomy.
We will keep our discussion in this section on fecal diversion.
A B
C D
Fig. 7: Types of stoma
Types 1 (Depending on the purpose for which the stoma is constructed)
y Diversion stoma – done to protect distal anastomosis (Ileostomy in cases with distal ileotransverse anastomosis or low colorectal anastomosis) or to exclude an obstructed system (Distal mass)
y Defunctioning stoma – In cases with distal diseased bowel to give bowel rest to that part of bowel (In cases of abdominal tuberculosis).
Types 2 (Depending on the part of bowel used) y Duodenostomy
y Jejunostomy – Watery clear dark green effluent start around 36 to 48 hrs after surgery y Ileostomy – Semisolid contents, dark green effluent
y Colostomy – formed fecal matter.
Types 3 (Depending on the duration for which it is constructed)
y Temporary stoma (diversion stoma for colorectal or ileotransverse anastomosis) y Permanent stoma (When entire distal bowel is resected such as abdominoperineal
excision of rectum).