Management of Crohn’s Disease

Abstract

Crohn’s disease is an inflammatory disorder characterized by focal inflammation along the gastrointestinal (GI) tract and may include extraintestinal signs. Management is initially medical with surgery reserved for treatment failure. However, surgery is also required with perforations, obstructions, and other serious manifestations. It is important for a surgeon to be aware of the clinical workup involved and the signs that warrant surgical intervention and to have the goal of preserving proper bowel function if intervention is necessary.

Algorithmic Approach

• A. Crohn’s disease usually presents in the third and sixth decades of life as a focal inflammation that can occur at any location along the GI tract from the mouth to anus, usually sparing the rectum. Symptoms include intermittent abdominal pain , diarrhea, and weight loss. Patients can also present with extraintestinal manifestations such as ocular disease, skin lesions, and joint disease. Initial evaluation includes a history and physical examination and should assess for previous episodes, family history of inflammatory bowel disease , and any prior treatments.

• B. A thorough workup of Crohn’s disease should include blood work and endoscopic evaluation to assess the level of inflammation and also to rule out possible malignancy. A computed tomography (CT) scan can be helpful to rule out specific abdominal pathology and may identify fistulas and abscess formation. Testing for perinuclear antineutrophil cytoplasmic antibody (p-ANCA) may be considered when the diagnosis is unclear.

• C. If the patient is having active disease, medical therapy is initiated. Treatment consists of steroids and biologic medications. If medical therapy is successful, the patient is followed closely and considered for remission therapy. If medical therapy fails in treating active inflammation and/or the patient’s symptoms worsen due to medical treatment (i.e., steroids), surgical intervention should be considered. Patients should also be considered for surgery if they demonstrate signs of peritonitis, bowel obstruction, signs of perforation, toxic megacolon , concern for malignancy, and/or fistulas.

• D. In the operating room, the goal is disease resection with gross margins. Patients with Crohn’s disease will oftentimes require multiple surgeries in their lifetime. It is important to be mindful of short-gut syndrome, which can be a devastating complication of multiple bowel resections. If large segments of bowel are involved or a patient has multiple previous bowel resections, stricturoplasty should be considered over segmental resection.

Algorithm 50.1