Inflammatory Bowel Disease - A Holistic Perspective
Perhaps the most well established yet enigmatic relationship is between smoking and inflammatory bowel disease (IBD). IBD typically is divided into UC and Crohn's disease (CD). The onset of these disorders is influenced by both genetic and environmental factors. Surprisingly, smoking has opposite effects on CD and UC. In UC, smoking may protect against or delay onset of disease and ameliorate its course, whereas in CD smoking may lead to earlier onset and worse prognosis. These opposite effects have been the subject of intense clinical and laboratory study in hopes of better insights into the pathogenesis and treatment of these disorders.
Modern pouch surgery leaves behind only a small cuff of rectal mucosa, of 1 or 2 cm at the most, when a doublestapled anastomosis is formed. No rectal mucosa should remain when the anastomosis is hand sewn in conjunction with a distal rectal mucosectomy. However, in some cases, for example in obese patients when it is difficult to bring the small bowel deep into the pelvis, the surgeon may need to leave behind a more substantial cuff of rectal mucosa to which the pouch is anastomosed. The term cuffitis has been used to describe persistent inflammatory bowel disease (IBD) in the remnant of rectal mucosa. Most often it occurs in patients who had active colitis before surgery. Symptoms are proportional to the amount of rectal mucosa that remains and to the severity of the inflammation. Patients complain of fecal frequency and urgency and the motions are commonly watery with mucous and blood. Urgency and leakage occur, especially at night. Rarely, if several centimeters of rectum remain,...
Twenty-seven BD patients were studied, all of them fulfilled the International Study Group (ISG) criteria for BD8. None of the BD patients had inflammatory bowel disease (IBD), nor a first-degree family relative with IBD. Furthermore, none of the patients had gastrointestinal manifestation of BD.
Complementary medicine use by patients with inflammatory bowel disease. Am J Gastroenterol 1998 93 697-701. Hilsden RJ, Meddings JB, Verhoef MJ. Complementary and alternative medicine use by patients with inflammatory bowel disease an internet survey. Can J Gastroenterol 1999 13 327-32. Hilsden RJ,Verhoef MJ. Complementary and alternative medicine evaluating its effectiveness in inflammatory bowel disease. Inflamm Bowel Dis 1998 4 318-23. Hilsden RJ, Verhoef MJ, Best A, Pocobelli G. Complementary and alternative medicine use by Canadian patients with inflammatory bowel disease results from a national survey. Am J Gastroenterol 2003 98 1563-8. Jacobs BP, Dennehy C, Ramirez G, et al. Milk thistle for the treatment of liver disease a systematic review and meta-analysis. Am J Med 2002 113 506-15. Spanier JA, Howden CW, Jones MP. A systematic review of alternative therapies in the irritable bowel syndrome review . Arch Intern Med 2003 163 265-74. Verhoef...
Ulcerative colitis (UC) and Crohn's disease (CD), collectively referred to as inflammatory bowel disease (IBD), are diagnosed most commonly in patients in their childbearing years. The incidence of CD in young adults is increasing, whereas the incidence of UC affecting patients in their reproductive years has remained stable. The etiology of IBDs is unknown, but clearly genetic factors and tobacco use have been implicated. Women routinely express concern about sexual intimacy, self-esteem, marriage, fertility, offspring inheritance of IBD, role of disease activity during pregnancy, safety of medications, and, finally, outcome or general health of the fetus. The most important issues for the patient are education and optimal timing of the pregnancy.
The diagnosis of dysplasia in inflammatory bowel disease (IBD) is a subjective interpretation and requires an experienced pathologist for optimum accuracy. Because major clinical decisions rest on the histologic diagnosis, it is imperative that the colonic biopsies be evaluated by a pathologist who has expertise in the diagnosis of IBD and the associated neoplastic transformation. This caution is especially true when the diagnosis of dysplasia is made. For example, we recommend colectomy for high grade dysplasia (HGD), but usually not for low grade dysplasia (LGD). Thus, unless the pathologist is experienced in the interpretation of dysplasia, get a second opinion on biopsies that will change clinical management.
The diagnosis can be even more difficult in a number of clinical settings. Patients who are immunocompromised, through diseases or medications, and patients at both extremes of age commonly have atypical histories and physical findings. Radiographic studies can be helpful in these patients. Gynecological conditions can be distracting in female patients. A pelvic examination, if not a pelvic ultrasound, is always warranted in this population. Young patients with conditions such as otitis media, streptococcal pharyngitis, meningitis, and mesenteric lymphadenitis may have abdominal complaints which can masquerade as appendicitis. Inflammatory bowel disease should always be considered in a patient with right lower quadrant abdominal pain. A final important consideration is the differential diagnosis of typhlitis, or neutropenic enterocolitis, in neutropenic patients undergoing chemotherapy for onco-logic conditions.
Aside from the complications inherent to abdominal procedures in general, several complications are relatively specific to this operation including sexual dysfunction, nonhealing of the perineal wound, and complications related to the ileostomy stoma itself. Sexual dysfunction (erectile dysfunction or retrograde ejaculation in men and dyspareunia in women) has been reported in up to 11 of men undergoing proctectomy for inflammatory bowel disease (9) and up to 50 of women (10). Even with the use of intersphincteric proctectomy, nonhealing of the perineal wound remains a significant problem, occurring in 11 of patients operated on for ulcerative colitis and 33 of those operated on for Crohn's disease (11). Complications related to the ileostomy are reviewed earlier.
Blood separate from faeces is most commonly due to haemorrhoids, but may also be due to a variety of other causes, including rectal carcinoma and proctitis, which can be associated with a mucous discharge. Is the blood fresh - bright red, or old - darkish brown this can help indicate where the bleeding is from. When does the patient notice it A proctoscopy should be carried out, but it may be that further investigation may be needed outside of our realm of care, in which case refer appropriately. Blood mixed with faeces may be due to Crohn's disease, or inflammatory bowel disease, carcinoma or vascular abnormalities, and the patient should be referred for careful investigation via a gastroenterologist (Rhodes & Hsin, 1995).
PEG has been used for nutritional supplementation in patients with inflammatory bowel disease (IBD), short gut syndrome, and malabsorption syndrome. It has also been used in patients with normal swallowing, but inadequate oral intake, to improve their nutritional status. Examples include patients suffering from extensive burns, acquired immunodeficiency syndrome (AIDS) wasting syndrome, anorexia after bone marrow transplantation, and chronic illnesses, such as cystic fibrosis and congenital heart disease. However, the role of enteral feeding in AIDS wasting syndrome is controversial.
Inflammatory Bowel Disease There are many studies that have examined the role of diet in inflammatory bowel disease (IBD) but there is no evidence that specific immune-mediated reactions to food play a role in the majority of patients with either CD or ulcerative colitis. Elemental enteral feeding and parenteral nutrition can assist in the management of IBD patients with benefits that appear related to improved nutrition and bowel rest (and decreased fecal flow) rather than removal of specific allergens from the diet. Patients in remission should be encouraged to eat a nutritionally balanced diet without restrictions unless they experience intolerance to specific foods. It is typical for IBD patients to be instructed to avoid dairy products but this is unnecessary in most cases. Apart from those with symptomatic lactose intolerance (in which case they should still be able to eat most cheeses and yogurts) or rare instances of cow's milk protein allergy, IBD patients should be...
In this chapter, treatment of SD is briefly reviewed. Not discussed are diarrheal diseases with a secretory component included in other chapters in this volume, including (1) infectious diarrheas, (2) diarrheas owing to bile salts or fatty acids, and (3) diarrhea owing to inflammatory diseases such as inflammatory bowel disease. This chapter focuses on the treatment of the remaining causes of SD, including those owing to hormone-related diarrhea, surreptitious use of laxatives, and SD of unknown origin.The hormone-related diarrheas include vasoactive intestinal secreting tumors (VIPomas), gastrinomas causing ZollingerEllison syndrome, glucagonomas, somatostatinomas, medullary thyroid cancer, and systemic mastocytosis.
Primary sclerosing cholangitis (PSC) is a chronic cholestatic disorder of unknown causation that is frequently associated with inflammatory bowel disease (IBD). PSC is characterized by diffuse inflammation and fibrosis of the biliary tree and usually leads to biliary cirrhosis, which can be complicated by portal hypertension and liver failure.
When mild distal disease is not controlled with this approach, or the disease is more severe, combined rectal 5-ASA (4 g d enema) and oral 5-ASA (2.4 to 4.8 g d) may prove effective. Alternatively, the addition of a hydrocortisone enema or hydrocortisone foam may be given once daily in addition to the oral 5-ASA therapy for a period of 3 to 4 weeks. If remission is not accomplished with this regimen, then prednisone 40 mg d for 2 to 4 weeks, in addition to oral 5-ASA, maybe used. Once symptoms are controlled, pred-nisone may be reduced by decreasing the daily dose by 10 mg each week down to 20 mg d, then reducing the daily dose by 5 mg per day each week or 2 weeks until the prednisone is stopped. Oral 5-ASA therapy (2.4 to 4.8 g d) may be continued for long term maintenance therapy. For the patient who responds to oral prednisone but promptly worsens as the dose is reduced despite maintenance therapy with 5-ASA, then azathioprine (AZA) or 6-mercaptopurine (6-MP) can be added. We check...
Consider four views of patients and their symptoms that may guide responses (McHugh and Slavney, 1998 Edwin, 2001). The viewpoint of disease assumes that the patient's complaints are caused by a broken body part or system this may imply either a disease of peripheral organs (inflammatory bowel disease or pancreatitis), a disease of brain (delusional depression, schizophrenia, dementing illnesses) or their interaction (metabolic encephalopathy). This is the arena in which physicians are most comfortable and effective, and in which referral or disposition becomes straightforward. The trait method focuses on temperamental attributes (like intelligence or dependency) that render individuals vulnerable to exaggerating, enhancing or otherwise distorting the problems and symptoms of illness. The viewpoint of behavior focuses attention on voluntary choices to sustain hunger or to eat, to remain sober or to drink and the intended and unintended consequences of these decisions. It becomes...
Year after an initial course of steroid therapy, specific strategies focusing on steroid sparing need to be considered early in the management of these patients. Corticosteroid therapy should be tapered off once a good response is achieved. We typically taper steroids at a rate of 5 mg equivalent of prednisone every 1 to 2 weeks. Other standard medical therapies should be initiated before taking steroids or if disease flares up upon steroid withdrawal. Mesalamine (Pentasa) at 4 g d may allow steroid-withdrawal and decrease steroid dependency following steroid-induced remission. Agents that have been shown to have steroid-sparing benefit include AZA, 6-MP, MTX, and infliximab. In pediatric population where growth retardation from corticosteroids is of particular concern, initiation of 6-MP concurrent with steroid therapy at the initial diagnosis has been recommended by some. There is a separate chapter on inflammatory bowel disease therapy in children and adolescents (see Chapter 67,...
Substantial morbidity, including scarring, continual seepage, and fecal incontinence, complicate perianal CD. Therapy is not standardized and debate continues on the role of operative intervention. The aim of this review is to discuss the perianal complications of inflammatory bowel disease (IBD) and provide appropriate surgical solutions.
Surveillance strategies for inflammatory bowel disease. Strategy A requires annual to biannual colonoscopy for the lifetime of the patient Strategy B stratifies patients according to neoplastic risk. PSC primary sclerossing cholangitis UC ulcerative colitis.
The presence of an abdominal mass or tenderness suggests the presence of concomitant conditions causing diarrhea, such as inflammatory bowel disease (IBD) or a neoplasm. Since up to 20 of tertiary referral patients with diabetes may experience fecal incontinence, an anorectal examination should be performed (Camilleri, 1996). The anorectal examination includes inspection of the external anal area for the presence of rectal prolapse, digital assessment of the sphincter tone at rest and during squeeze, and assessment of alterations in sensation (eg, pinprick around anal verge).
Myeloperoxidase (MPO), an enzyme found in the azurophil (primary) granules of neutrophils, is a homodimer with a molecular weight of approximately 140 kDa. MPO-ANCA is the diagnostic marker for MPA in general (sensitivity 60-80 ) as well as a diagnostic marker for immunohistologically negative ( pauci-im-mune ) focal necrotizing glomerulonephritis, which - when inadequately managed - can transform into extracapillary proliferative, rapidly progressive glomerulonephritis (RPNG). Pauci-immune glomerulonephritis can occur as a component of systemic vasculitis (especially MPA) or as an idiopathic type (without signs of extrarenal vasculitis). MPO-ANCAs are detectable in roughly 65 of patients with this type of glomerulonephritis. Exogenous factors such as medications (mainly hydralazine and propylthiouracil, but also penicillamine, methimazole, allo-purinol, and sulfasalazine) or silica exposure are currently being discussed as potential triggers in some of these cases. MPO-ANCAs are also...
It may be more important to understand the health beliefs and behaviors of those who use CAM. CAM users often want to play a more active role in their health care.We found that important factors leading inflammatory bowel disease (IBD) patients to use CAM included dissatisfaction with their conventional medical treatments, especially a lack of effect or side effects of medical treatments. However, other factors are also important including a patient's health beliefs, culture and knowledge and their previous experiences with CAM. Some patients' health beliefs may be more compatible with CAM, and therefore, they may use them
Function, or recurrence proximal to the pouch should the diagnosis in fact be CD. Fortunately, infliximab therapy has been effective for many patients who have developed CD in an ileoanal pouch. More detailed discussions of perianal disease management of CD and of dysplasia surveillance are discussed in other chapters (see Chapter 81, Perianal Complications in Crohn's Disease, Chapter 82, Perianal Disease in Inflammatory Bowel Disease and Chapter 83, Dysplasia Surveillance Programs ).
Related and requires monitoring with full blood counts weekly for the first month and then subsequently at least four times annually. Thioguanine has been used successfully for patients with allergies to AZA or mercaptopurine, or for patients with high functional thiopurine methyl-transferase activity however, the risk of hepatic complications such as veno-occlusive disease or nodular regenerative hyperplasia has limited the utility of this end product of mercaptopurine metabolism. AZA and 6-MP are also beneficial in perianal disease, including fistulas, and should be continued if tolerated as first line maintenance therapy. There is a separate chapter on AZA use in IBD (see Chapter 69, Monitoring of Azathioprine Metabolite Levels in Inflammatory Bowel Disease ).
Most people are at average risk for colorectal cancer simply because they have reached the age when the prevalence of cancer is sufficient to justify screening. Based on age-incidence curves for this disease, guidelines recommend that screening of the average-risk population (both men and women) begin at the age of 50 years. Reported direct screening colonoscopy experiences in people age 40 to 49 years confirm the very low prevalence of advanced neo-plasia in average-risk people under age 50 years of age. Patients with a personal or family history of colorectal cancer or adenomas, or those with long standing ulcerative colitis (UC) or Crohn's colitis may have a higher risk of colorectal cancer that often begins at an earlier age, and these patients may benefit from special, more intensive examination or screening. Screening recommendations for these high risk groups are clearly outlined in the GI Consortium Guideline (Winawer et al, 2003) and will not be discussed further here. There...
The diagnosis is confirmed by demonstration of an increased serum VIP level by radioimmunoassay. An increased a-chorionic gonadotropin suggests malignancy.42 The differential diagnosis should include villous adenoma, inflammatory bowel disease, infectious diarrhea, celiac sprue, surreptitious laxative abuse, and other endocrine tumors such as gastrinoma, somatostatinoma, medullary thyroid carcinoma, and carcinoid tumors. At present, there are no known provocative or inhibitory agents to secure an otherwise equivocal diagnosis.
Several lines of evidence suggest that factors other than glucocorticoids contribute to bone loss in inflammatory conditions of the bowel. Patients with recently diagnosed inflammatory bowel disease (IBD) do not have decreased bone mass density compared with age-matched controls however, those with symptoms of 6 months duration have lower bone mass density than age-matched controls (Stockbrugger et al, 2002). A variety of cytokines are overproduced in IBDs and celiac disease and may have detrimental effects on BMD. The inflammatory cytokines IL-1 p, IL-6 and TNF-a are elevated in the systemic circulation of patients with CD. In patients with celiac disease, there is increased IL-1p and IL-6 in the systemic circulation which correlates with osteopenia. TNF-a expression is also increased in the mucosa of celiac patients, and, recently, treatment with infliximab has been shown beneficial in a patient with gluten-insensitive, refractory disease (Gillett et al, 2002).
The primary end point was corticosteroid-free remission (CDAI 150, corticosteroid dose 0) at wk 14. Other secondary end points included corticos-teroid utilization and quality of life, assessed by the Inflammatory Bowel Disease Questionnaire (IBDQ). Additional response levels included low-dose steroid-dependent remission (CDAI 150, corticosteroid dose 10 mg d),
Editor's Note There is a separate chapter on AZA use in inflammatory bowel disease (see Chapter 69) which sites a 70 response rate if TPMT actually is less than average but only a 20 to 40 response and increased toxicity if TPMT levels are above average (Cuffari et al, 2004).
The patient with a history of inflammatory bowel disease poses a challenge to the surgeon in the selection of an appropriate bowel segment for diversion. Clearly, the use of the large bowel is to be avoided in the patient with ulcerative colitis. Likewise, the terminal ileum should not be used in patients with a history of Crohn's disease. This is particularly problematic because Crohn's disease may involve the entire gastrointestinal tract. In this situation, the use ofjejunum or stomach is preferable to the terminal ileum in the construction of the diversion. Ileal conduits are relatively contraindicated in children because of the risk of associated long-term chronic pyelonephritis and renal deterioration. Contraindications for orthotopic neobladder include tumor in the prostatic urethra, or in females, tumor at or near the bladder neck.
There is no consensus on whether inspecting the terminal ileum is a necessary part of every total colonos-copy. Intubation is often difficult and requires an experienced examiner. However, there are some patients in which pathologies are present only in the terminal ileum (e.g., Crohn disease). And, for certain indications (diarrhea, suspected chronic inflammatory bowel disease, unexplained gastrointestinal bleeding), examination of the terminal ileum is essential. At our center we therefore aim to perform an intubation of the Bauhin valve on every patient, in part given the benefit of practical experience gained by the examiner in performing this technique.
Nonsteroidal anti-inflammatory drugs can also induce colitis, which may not be visibly discernible from infectious colitis or chronic inflammatory bowel disease (Figs. 13.29,13.30). However, its endoscopic aspect can also include flat and usually irregularly bordered erosions and ulcerations, which are surrounded by an otherwise normal appearing mucosa (s 13.5). Individual lesions may bleed.
We are beginning to have some experience with inflixamib (Remicade) in the setting of surgery for inflammatory bowel disease. it appears that patients with aggressive fis-tulizing CD may best be prepared for surgery by a period of treatment with Remicade to minimize inflammation and cool off areas of extensive fistulization. Thus far, operating upon patients recently treated with Remicade does not appear to have significant risks. The experience is early, however. A few of these patients with fistulization have been left on inflixamab postoperatively.
Urogenital fistulas may occur congenitally, but are most often acquired from obstetric, surgical, radiation and malignant causes. The same factors may be responsible for intestinogenital fistulas, although inflammatory bowel disease is an additional important aetiological factor here. In most developing countries over 90 of fistulas are of obstetric aetiology, whereas in the UK and USA over 70 follow pelvic surgery.
The lesions of RAS may be associated with inflammatory bowel disease (IBD), such as ulcerative colitis and Crohn's disease. Simple or complex aphthosis may antedate, coexist, or serve as a marker for increasing intestinal disease activity. Patients with IBD not only have lesions of RAS but may also have erythema nodosum, papulopustular lesions or lesions of pustular vasculitis, and inflammatory ocular disease such as iritis and uveitis. Thus the distinction between multisystem IBD and BD may be difficult18-21.
Some of the side effects of NSAIDs on the large bowel are rare, such as erosions, solitary or multiple ulcers, inflammation (which may resemble classic inflammatory bowel disease IBD ), aggravation of diverticulitis, or even appendicitis in the elderly (Bjarnason et al, 1987). Treatment is the same as for the underlying disease, with discontinuation of the particular NSAID and with COX-2 selective agents being the preferred antiinflammatory analgesic.
Peritoneal dialysis catheters can be placed via an open or percutaneous method. General contraindications to catheter placement include abdominal wall hernias or infections, active inflammatory bowel disease, diffuse intraabdominal adhesions, respiratory insufficiency, and gastrointestinal stomas (11). The Tenkhoff catheter, which is made of Silastic and equipped with two Dacron cuffs, is the most commonly used PD catheter. Placement by the open method is done in the operating room under general or local anesthesia. A small infraumbilical midline incision is used to better allow the catheter to reach into the dependent pelvis. (A supraumbilical incision can be utilized in patients with previous lower abdominal surgery to avoid adhesions.) The abdominal wall fascia is opened, a purse-string suture placed into the peritoneum, and a catheter guide used to direct the catheter toward the pelvis. The purse-string suture is tied down, securing the catheter in position with a watertight seal...
Diverticulitis and inflammatory bowel disease. Patients with a history of symptomatic diverticulitis must be evaluated for partial colectomy before transplantation. Inflammatory bowel disease generally should be quiescent at the time of transplantation. (From Kasiske and coworkers 1 with permission.)
In most cases, there are no significant sequelae following the diarrheal illness. However, in some cases that present as travelers' diarrhea, underlying illnesses may be unmasked. This is particularly true for irritable bowel syndrome and inflammatory bowel disease. These are usually recognized after a traveler develops a persistent diarrheal illness during travel. During the diagnostic work-up (usually done after returning from travel) these underlying diseases are identified. Tropical sprue has also occasionally been diagnosed in travelers with persistent diarrhea.
Dramatic changes have occurred in the understanding and management of inflammatory bowel disease (IBD) over the past decade. The interaction of luminal contents with the gastrointestinal (GI) immune system has enhanced our understanding of mucosal inflammation and has improved the focus of general management. Biologic therapy is coming of age and dozens of new silver bullet compounds are being developed to treat both Crohn's disease (CD) and ulcerative colitis (UC). In the midst of the excitement about what the future holds, it is important to focus on maximizing the treatment options that are currently available. I will review the current understanding of left-sided UC and issues regarding management of mucosal inflammation and symptoms of this disease.
Inflammatory bowel disease (IBD) patients must deal with socially embarrassing, painful, and, sometimes, body image altering diseases. They experience better outcomes when they are adequately educated about their disease process and treatment and have confidence that there is a reliable contact when problems or questions arise. These patients need to feel comfortable discussing their symptoms and fears in a relaxed atmosphere of empathy, compassion, and professionalism. They deserve accurate information given in a timely manner. Unfortunately, many patients report dissatisfaction in accessing the health care system. In large institutions it is easy for the patient to feel he she gets lost in the shuffle in the interim between regularly scheduled visits. Blaine Franklin Newman became frustrated with the inconsistent contacts and information he dealt with during his battle with Crohn's disease and vowed to help other patients avoid that distress. His generosity and foresight provided...
Small intestine have long been considered important in the genesis of IBS-associated symptoms. A second pathogenetic mechanism may be visceral hypersensitivity whereby nonpainful intra-abdominal stimuli become painful (alldynia) or painful stimuli become more painful (hyperalgesia). Whether visceral hypersensitivity is due to hypervigilence or sensitization of sensory pathways by an acute event has not been determined. A third potential pathophysiologic abnormality in IBS is abnormal central processing of peripheral information as evidenced on proton emission tomography or functional magnetic resonance imaging. Although psychiatric factors are not considered to be the major cause of IBS, there is abundant evidence that psychological disorders are more common in patients with IBS when compared with either the general population or with medical control patients, such as those with inflammatory bowel disease. Recently, a role for infection in the genesis of IBS has been suggested. Many...
Interest in probiotics has stemmed from the accumulating suggestive evidence that bacterial products play a role in the pathogenesis of inflammatory bowel disease (IBD) (Kleessen et al, 2002 Martin and Rhodes, 2000 Schultsz et al, 1999) and that certain beneficial bacteria may have anti-inflammatory properties (Borruel et al,2002). A small pilot study looked at four children with mild to moderate CD treated with Lactobacillus GG and showed significant improvement in mucosal permeability and clinical activity over the 6-month study period (Gupta et al, 2000). Little other data is available on pediatric CD. Despite this, many of our patients are using probiotics and other complementary and alternative therapies. There is a separate chapter on alternative medicines (Chapter 58, Complementary and Alternative Medicine in Gastrointestinal Disease ). Probiotics are discussed in chapters on ulcerative colitis (Chapter 78, Ulcerative Colitis ) and on pouchitis.
Of the interstitium tubular atrophy, and fibrosis. Several atrophic tubules are surrounded by one or more layers of a-smooth muscle actin positive cells. The patient had normal renal function on beginning treatment with 5-ASA. After 5 years of 5-ASA therapy, the patient demonstrated severe impaired renal function. The association between the use of 5-ASA and development of chronic tubulointerstitial nephritis in patients with inflammatory bowel disease (IBD) has gained recognition in recent years 27,28 . (Courtesy of ME De Broe, MD.)
Fixed strictures of the small or large intestine need to be distinguished from extrinsic compression or acute gut angulation as a consequence of adhesions. They must also be distinguished from dynamic processes to include mural spasm, intussusception, and volvulus. Colonic strictures are most common, particularly following anastomoses in which there is a postoperative leak, pelvic abscess, or previous pelvic irradiation (Kozarek, 2001 Kozarek, 2003). Table 85-1 outlines additional causes of benign and malignant colonic strictures. Intestinal strictures, in turn, are mostly inflammatory and are the consequence of acid-peptic disease and nonsteroidal anti-inflammatory drug (NSAID) use in the proximal gut and inflammatory bowel disease (IBD) and anastomotic cicatrization in the mid and distal small bowel. Other etiologies are listed in Table 85-2. Drop metastases (gastric) Inflammatory bowel disease Crohn's
Diverticulosis Angiodysplasia Cancer Polyps Inflammatory bowel disease Radiation proctocolitis Infectious colitis Ischemic colitis Anorectal disease Hemorrhoids Anal fissures Rectal ulcers Fistula in ano Rare Causes Portal hypertensive colopathy Small bowel varices Colonic and rectal varices Endometriosis
In coronary balloon angioplasty, increased extracellular matrix deposition frequently occurs, leading to restenosis. Studies have shown increased type I collagen production following experimental angioplasty, as well as decreased MMP activity (119). The broad-spectrum MMP inhibitor Galardin 2 reduced both collagen synthesis and degradation in an iliac artery model of restenosis following balloon angioplasty. Increased matrix turnover has also been linked to the destabilization of atherosclerotic plaques (120), and elevated gelatinase-B activity has been implicated as a causative factor in the enlargement of abdominal aortic aneurysms (40). Other diseases that have been considered as targets for MMP inhibitor therapy include emphysema (121), gastric ulcers (122), and inflammatory bowel disease (123). In each case, there is evidence to suggest that MMPs secreted by inflammatory or stromal cells are responsible for the tissue remodeling and degradation that occurs in these conditions.
Therefore, angiography can be helpful in those patients who have undergone multiple previous procedures or in whom regional or distant tissue flaps are being considered to aid in reconstruction. Finally, an evaluation for the presence of GI pathology, including enterocutaneous fistula, inflammatory bowel disease, other inflammatory processes including diverticular disease, or recurrent tumor is vitally important before allowing the patient to enter the operating room. Optimization of these problems and their associated comorbidities, including malnutrition, abscess drainage, and assessment and control of the extent of any underlying GI pathology are of the utmost importance both in the short term postoperative outcome and in long term results of abdominal wall reconstruction.
The extra-intestinal manifestations of inflammatory bowel disease (IBD) including inflammatory symptoms of the joints, eyes, skin and liver are more common in patients with colonic disease than in patients with disease limited to the small bowel. There are also environmental factors contributing to CD of the colon cigarette smoking protects against UC such that patients with indeterminate colitis who are smokers are much more likely to evolve to CD. In contrast, the NOD2 genotype is not seen to the same degree in patients with Crohn's colitis compared to CD disease patients with ileal disease (Brant et al,). Similarly, serologic markers to distinguish UC from CD are not as reliable in Crohn's colitis due to the lack of specificity of myeloperoxidase (pANCA) antigen to distinguish UC from Crohn's colitis and the lack of sensitivity for anti-saccharomyces cerevisiae antibodies (ASCA) in colonic CD. Crohn's colitis patients positive for pANCA tend to have left-sided UC-like colitis,...
Malabsorption of vitamin B12 is most often a result of an autoimmune-induced Pathogenesis deficiency of intrinsic factor (pernicious anemia), but can also be caused by a vegan diet, inflammatory bowel disease, gastric or ileal resection, and nitrous oxide anesthetic. Cobalamin is required for methionine synthase and methyl-malonyl CoA reductase, which influence myelin basic protein and sphingomyelin production.
Because the responses to therapy are not consistent, the clinician often needs to take an empirical approach to therapy. It is reasonable for the clinician to try therapies in the order of using those therapies with the best side effect profile first. For example, there are several reports of patients with the classic and inflammatory phenotypes of EBA who responded to high doses of colchicine (Megahed and Scharfetter-Kochanek 1994 Cunningham et al. 1996). Colchicine is a good first-line drug because its side effects are relatively benign compared with other therapeutic choices. One problem with colchicine is that many patients with EBA have inflammatory bowel disease, and the predictable, dose-dependent, gastrointestinal side effects of colchicine makes it unusable in these patients. Even patients without clinically defined inflammatory bowel disease may not be able to tolerate even the lowest doses of colchicine without suffering abdominal cramping and diarrhea. It is unclear how...
Histopathological analysis can help distinguish between acute infectious enterocolitis vs. early stages of a chronic inflammatory bowel disease. A very high degree of neutrophilic infiltration and severe edema tend to indicate infectious colitis. Severe crypt distortion is more indicative of UC, while discontinuous, focal cryptitis supports a diagnosis of CD. Granulomas may be absent with CD, but, alternatively, they may be found in tuberculosis and yersiniosis.
Mild stenosis with minimal symptoms can usually be managed with dietary modifications and bulking agents, with the intention of naturally dilating the anal canal. Self-dilation using a Hegar's dilator may result in hematoma formation and further fibrosis. Therefore, we do not recommend this method, except possibly in some patients with strictures secondary to inflammatory bowel disease. Patients who fail conservative management and have satisfactory sphincter pressures may be treated by surgical sphincterotomy. However, this technique does not treat the ectropion, which is a protrusion of mucosa onto the ano-derm that may be associated with the stenosis. There is a separate chapter on dilations of intestinal and colonic strictures (see Chaper 86, Acute Colonic PseudoObstruction ).
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