Influence of Proximal Disease

Does removal of proximal disease improve perianal disease in patients with CD? It has been shown that removal of all proximal disease does in fact promote healing in the perineum. Moreover, if proximal disease recurs, then the chance of recurrence in the perineum is also increased. Wolff and colleagues (1985) supported this conclusion with a report of 86 patients. In those patients with complete resection of proximal disease, only 29% developed recurrence. In those who had incomplete resections, 63% developed recurrent anorectal disease. However, in our opinion, proximal disease should be removed only when symptomatic as the influence of proximal resection or perineal disease is uncertain.

Fecal Diversion

The effect of fecal diversion or activity of perineal CD is controversial. Yamamoto and colleagues (2000) found no improvement in perianal disease with proximal diversion. over the years, this practice had been frowned upon because of the historically low rates of restoration of continuity. This negative experience, however, predates combination therapy using antibiotics, azathioprine or 6-mercaptopurine, infliximab, cyclosporine, or tacrolimus. Given the current ease of laparoscopic loop ileostomy and the use of these newer medications, fecal diversion may again have a place in our overall treatment of perianal CD.

Proctectomy

Proctectomy is uncommonly performed in patients with perineal CD; between 5 to 25% of patients will ultimately require proctectomy. In our own long term series of patients with anorectal CD, two groups have emerged. The first had suffered severe rectal involvement and proceeded to proctectomy very early in the disease process. The second group had more limited rectal disease and has been managed well with conservative treatment. Within this series, the cumulative probability of avoiding proctectomy was 92% at 10 years and 83% at 20 years (Wolff et al, 1985). Despite good results with intensive medical and surgical therapy, a small percentage of patients will ultimately require proctectomy. As perineal wound complications are a major source of morbidity, an intersphincteric dissection to decrease morbidity is performed routinely (Lubbers, 1982). In patients with severe perianal sepsis, a diverting laparoscopic ileostomy followed by proctocolectomy in 6 to 12 weeks results in fewer wound complications. For patients who have persistent perianal pain, discharge, or incontinence despite maximal medical therapy, proctectomy offers a substantially improved quality of life.

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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