Welcome to First Incision, the podcast about preparing for the General Surgery Fellowship exam. I'm your host, Amanda Nikolic. Let's get into it with our team timeout. Our patient today is the colorectal module from the general surgical curriculum and our operation or the topic we're going to be covering today is to finish off inflammatory bowel disease. So I'm going to be talking about perianal Crohn's disease.
the special population of women attempting to or becoming pregnant with Crohn's disease, and I'll also briefly be mentioning indeterminate colitis. So starting off with perianal Crohn's disease, 20% of patients with Crohn's will develop some form of perianal Crohn's disease. There's a number of different, I guess, types of perianal disease that are associated with Crohn's.
The first of these is skin tags, but these are not like normal skin tags. These are quite large lumps. They can be sort of waxy and described as elephant ear, quite thickened and abnormal. Patients can develop anal fissures or Crohn's fissures, which can occur anywhere around the circumference of the anal canal. And these are typically different in shape to normal fissures.
They're sort of more of an ulcer and are not associated with hypertonia. Patients can get fistulas disease, and these fistulas typically don't ascribe to Goodsall's law. They can be described as a water can appearance and often complex with abscesses and undrained areas. Patients can develop anorectal strictures over time due to inflammatory and then fibrotic scarring.
and can also develop hydroadenitis type picture. And last but not least, patients with Crohn's disease can develop perianal cancers. The diagnosis of these diseases is typically made via an examination under anaesthetic. This is how you can assess the extent of disease, location, how much of the sphincters are involved.
and typically would be combined with a colonoscopy to determine the extent of colonic involvement of Crohn's disease. An MRI is another adjunct that can be used to delineate fistulas tracts. for deep sepsis and determining whether there is any deep undrained sepsis and also for helping you to plan management. In general, the principles for perianal Crohn's disease is to try not to intervene if you don't have to.
So you want to avoid removing any skin tags, avoid fistulotomies and preferences to use long-term setons rather than to do surgical interventions for this disease. Your focus should be on draining sepsis. These patients need a multidisciplinary approach as this is complex disease management. Patients should have concomitant medical management and typically for perianal Crohn's disease, infliximab therapy, which is one of those monoclonal antibodies against tumor necrosis alpha.
is the mainstay of medical management that's been demonstrated to improve perianal Crohn's disease. Carefully selected patients without active disease may benefit from surgical management of fistulas. And one of your main priorities should be to preserve sphincter function. So just talking a little bit about the different types of disease patients get and the approaches to these. First one I'll talk about is fissures.
So as I mentioned, these can occur anywhere around the circumference of the anal canal, unlike fissures that are associated with non-Crohn's patients, which are typically found at the 0 and 6 o'clock position. These fissures usually don't respond to normal methods of, you know, GTN and calcium channel blocking creams, Botox or sphincterotomy.
Not to say you can't do a lateral anal sphincterotomy if all else fails and the patient has significant cyst symptoms, but you really should try and avoid surgery if you can, especially if they have active proctitis. Abscesses can arise from distorted anal glands or deep ulcers and fistulas. The management of abscesses is control of sepsis with drainage and theatre.
and consideration of placing drains into deep cavities and also placing setons into any fistulas tracts. Management of fistulas, as I've mentioned, These can be extensive and usually don't ascribe to good source law. Vistulas in Crohn's disease can... sort of cross anatomical boundaries and do funny things and be quite deep and have multiple sort of sinus tracks. So it's important to really assess your disease with a
good examination under anesthetic and to use MRI as required to help you to find where the disease is. Again, you want to drain any abscesses or undrained areas. You want to treat with acetone. From there, the management of the fistula depends a little bit on the patient's disease activity. If you have active disease, then you should be treating...
with medical therapies like infliximab and doing no more surgically than acetone and managing sepsis. This does get a little bit more complicated in terms of if there is no active disease, patients have been treated medically.
about whether or not you do normal management of fistulas or what you would normally do in a patient who doesn't have Crohn's. I think this is all pretty controversial and very subspecialized. In general, if there is absolutely no... active disease and you're being really pushed to do something about the fistula in the exam, I guess you could say that you would consider fistulotomies, lifts or advancement flaps but I'd probably be pretty careful about saying that sort of thing in the exam.
The other controversial question is what to do been medically treated for their fistula and their active disease is all under control but the seton is still in the fistula. Do you remove the seton and when do you do that and I guess is that going to help? with that fistula heel if they're having a response to their treatments. Again, that's a little bit controversial. I don't really have a good answer to that. But in general, you'd be wanting to make those decisions as a multidisciplinary team.
The last thing to mention with perianal Crohn's disease is that patients who have significant disease, recurrent sepsis, lots of pain, for example, these patients could be considered for a defunctioning ileostomy. to improve their quality of life. And the natural history of perianal Crohn's disease is that 5% to 10% of these patients will require a proctectomy in order to manage their symptoms.
I thought next we could talk about inflammatory bowel disease and pregnancy. It seems to be a favourite question in the exam about what to do in patients who have pregnancy and other general surgical problems. So firstly, we'll talk about fertility. So patients with inflammatory bowel disease who have well-controlled disease have the same fertility rates as the general population, but there are some features of IBD that can reduce fertility.
Firstly, if patients have inflammation involving the fallopian tubes or the ovaries, this can reduce fertility in women. Perianal and pelvic inflammatory disease related to IBD can also cause dyspareunia for women. Medications can decrease fertility, especially in men. So specifically methotrexate and sulfasalazine can cause a reversible oligospermia and sulfasalazine can also reduce sperm motility.
And surgery can impact on fertility. So patients who've had pelvic surgery can develop impotence or ejaculatory difficulties due to injuries to pelvic autonomic nerves. Women who've had pelvic surgery can have reduced fertility due to scarring and adnexal adhesions. There's some important things that need to be discussed with patients with IBD prior to conception. So this includes a discussion about the potential inheritance of the risk of inflammatory bowel disease in children.
So IBD follows a non-Mendelian pattern of inheritance. So it's not an autosomally dominant or autosomally... recessively inherited gene that leads to IBD. But patients who have a first degree relative with IBD are between three and 20 times more likely to develop it compared with the general population. The second thing is disease control. So it's really important for patients who are trying to get pregnant to have their disease in remission at the time that they're attempting conception.
the reason is because patients who have active disease at conception are more likely to have problems with active disease throughout the pregnancy Patients with active disease are more likely to have antepartum hemorrhages, have low birth weight infants, and have premature delivery. Other things that are important to consider...
preconception in patients with IBD is their nutritional status and supplementations. So patients with IBD are more likely to be malnourished than general populations, so consultation with a dietician is important. In addition, patients require folic acid supplementation, which is recommended for all women now because it reduces the risk of neural tube developmental abnormalities.
Patients with IBD may be on low-residue diets or have ileal involvement or be on medications that interfere with folic acid metabolism such as sulfasalazine. So this is important for these patients. Patients may also be at risk for iron and vitamin B12 deficiency more than the general population, so it's important as well to measure these throughout the pregnancy and ensure that they are adequately replaced.
I think it's a little bit outside the scope of what we need to know as surgeons, but in terms of medications and pregnancy, IBD medications in general are suggested to be continued. because the risk of having a flare of the IBD and the effects of that on the pregnancy are higher than the risks of potential problems with the medications. And they've got a relatively good risk profile during pregnancy.
with the exception of methotrexate, which is associated with skeletal abnormalities and abortions. And this should be ceased for at least three months, but ideally six months prior to conception. The next topic to talk about with pregnancy and IBD is what to do with patients that do have flares or complications from their IBD during pregnancy. So the first thing is how do you work up those patients?
So MRE, a magnetic resonance enterography, is preferred as a diagnostic modality in pregnant patients with IBD. If you work at a hospital where they do ultrasound for IBD, then this is another alternative. Endoscopy should only be performed if there's a strong... indication and it's going to change your treatment decisions and it should be as limited as possible. So if a flexible sigmoidoscopy is possible, this would be preferred with minimal sedation over a full colonoscopy.
Patients who have complications from their IBD that warrant surgery and are pregnant still need this pathology addressed as... A sick mum equals a sick baby. So if there's something that needs to be managed for the mum, then that overall is going to improve the likelihood of that baby surviving. So indications for surgery in a pregnant patient are the same as those in a non-pregnant IBD patient. So this includes acute severe refractory disease, perforation.
development of abscesses, severe hemorrhage or obstruction. Surgery is associated with complications such as preterm labour and spontaneous abortions, but these are rare. And obviously, if the mum is very sick, then there's a high risk of these complications without surgery as well. The last thing to consider is the mode of delivery for these patients.
So in general, a normal vaginal delivery can be attempted in patients with inflammatory bowel disease, even if they have a colostomy, an ileostomy, and if they have a J pouch. Some people would suggest a planned caesarean for patients with ileal pouches and they should definitely be considered in patients with active perineal disease in order to avoid. Perineal trauma associated with a vaginal delivery. The last topic I wanted to touch on today is indeterminate colitis.
I think this is worth just talking about because some patients may have overlapping features clinically or on biopsies of UC and Crohn's disease and then they might be labelled as an indeterminate colitis. Looking through the literature, though, it doesn't look like there really is a clear definition of when somebody should be diagnosed with indeterminate colitis. And it looks like there's a lot of different perspectives from pathologists and specialists as to what that diagnosis actually means.
In our institution, we have an inflammatory bowel disease, MDM, where we can talk through these more complex cases. The reason that it's important to try and correctly establish a diagnosis of either ulcerative colitis or Crohn's disease in patients presenting with IBD is that obviously, as we've discussed, these... Pathologies have a different natural history, different surgical management. They may respond differently to different treatments and also have different...
disorders associated with them so for example PSC and ulcerative colitis. In general when we talk about surgery it's important To have a diagnosis, because if you do a total proctocolectomy and a ileal pouch on a patient who ends up having Crohn's disease, they can potentially have lots of problems with their pouch. So knowing that beforehand can be really helpful.
But obviously, there isn't a clear diagnostic criteria for UC and Crohn's disease. We make these diagnoses based on the clinical presentation, histopathological findings, and endoscopic appearances. And if you don't have... clear, hard signs or you have overlapping features or a difficult biopsy, then it may be difficult to clearly put somebody into one of those boxes and you also don't want to incorrectly diagnose somebody and give them the wrong treatment.
So some situations where it may be more difficult to tell whether or not a patient has UC or Crohn's disease can be in fulminant colitis. Typically, formative colitis is an initial presentation and you may not know at the time whether or not this is a UC presentation, which it mostly is. whether it's a complication of Crohn's disease or even if it's a completely different pathology such as a Clostridium difficile infection.
There are also some presentations, especially of ulcerative colitis, which have overlapping features with Crohn's disease. So this could include fissures or they can present with patchy disease if they've had partial treatment. They can even present with granulomas. which can look like Crohn's granulomas. So this can all confuse the picture.
And in addition, ulcerative colitis can even present with distal ileitis, although typically this is only in the last one to two centimetres and is thought to be due to backwash of seagull contents into the ileum causing an inflammation. The other thing to think about is whether this isn't an IBD presentation at all. So patients may be taking NSAIDs, may have an infection, may have bacterial overgrowth or ischemia, and all of these sorts of...
Pathologies could present clinically or in biopsies as similar to either UC or Crohn's. So if you ever come across a patient who's been diagnosed with indeterminate colitis, hopefully that gives you a little bit of an idea about what that might mean and that really it's a diagnostic uncertainty and they're saying there's something going on.
They're not really clear what box that patient should be put into yet. And in those situations, it's important to look at the clinical, histopathological and endoscopic findings. and any associated diagnoses, as well as to try to exclude those conditions that can mimic IBD. And if you have access to a specialty MDM, to have that patient discussed there to be reviewed by a specialty team.
And that wraps up our special episode on perianal Crohn's disease, pregnancy and IBD and indeterminate colitis. Hopefully I'll be having a specialist come onto the program soon to talk through some of the... different aspects of surgery in IBD patients. And in the meantime, please remember to rate, review and subscribe so other people can find this podcast.
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