NMS. Casos Clínicos

232 Part II ♦ Specific Disorders A CT scan of the abdomen reveals a stenotic segment of bowel in the terminal ileum region and no other suggestions of complications. Q: What is the management plan? A: If the stenosis is a fixed stricture, then resection is necessary because medical treatment will not improve the obstruction. If the obstruction is due to inflammation, then continued medical therapy may relieve the obstruction.

Digging Deep

The goal of surgery for Crohn disease is to relieve the obstruction while preserving as much normal bowel as possible. This would include the use of stricturoplasty, which opens a strictured area by cutting the stricture

longitudinally and repairing it transversely to expand the lumen.

Q: What problems should you anticipate in future years? A: Reoperation may be necessary; in some series, the rate of reoperation is as high as 50% for additional problems related to Crohn disease. Resection of the terminal ileum may also lead to problems because it is responsible for the reabsorption of bile acids and vitamin B 12 . Impaired bile acid absorption can cause diarrhea, depletion of the bile salt pool, and malabsorption as well as oxalate stones . Gallstones are more common, and vitamin B 12 deficiency may occur. Q: How would the management change if the CT scan demonstrated an internal fistula between two segments of small bowel? A: The management would remain unchanged. Management is based on patient symptoms and active problems, not radiologic findings .

Case 8.9  Perianal Disease in a Patient with Crohn Disease Q: How would you manage this patient? A: This patient’s condition poses a difficult problem, and surgery is generally indicated only to drain perirectal abscesses, if present. Management of superficial fistulas involves opening the tract. Setons are plastic tubes or sutures placed through the fistula that slowly allow the fistula to close. They are used for deeper fistula to allow healing to occur without injury to the sphincter. Metronidazole is useful in the management of the majority of patients with perianal problems. SAMPLE You are asked to care for a 20-year-old with Crohn disease and perianal disease. On examination, you note a tender perineum and inflammation.