NMS. Casos Clínicos

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Chapter 8 ♦ Lower Gastrointestinal Disorders

Case 8.10 Management of Crohn Colitis

You are caring for a 19-year-old patient with Crohn disease that involves the colon.

Q: How does Crohn disease in the colon differ from Crohn disease in the small bowel? A: Crohn disease of the rectum is an unfavorable, unrelenting problem that often leads to fecal diversion. When the disease is limited to the colon, 5-acetylsalicylic acid compounds have some effect in addition to steroids. When the disease is limited to the small bowel, 5-acetyl- salicylic acid compounds have little effect. If surgical complications are present, a subtotal colectomy is often needed and ileostomy if the rectum is involved. If not, then the ileum can be anastomosed to the sigmoid colon or rectum and continence retained.

Case 8.11 Complications of Long-Standing Ulcerative Colitis

A 36-year-old with a long-standing diagnosis of ulcerative colitis that has been man- aged medically consults you for advice on long-term prognosis and management. Q: What recommendations would you make? A: Ulcerative colitis is a mucosal disease limited to the mucosa and submucosa, whereas Crohn disease involves the whole intestinal wall. Individuals with ulcerative colitis are at an increased risk for developing colorectal cancer, which is related to the dura- tion of their illness and the extent of disease. The risk for developing cancer is gener- ally low for the first 10 years of the ulcerative colitis (2%–3%) but then increases by 1%–2% a year. Thus, the risk of colon cancer may be as high as 20% in a patient who has had ulcerative colitis for 20 years. The American Gastroenterological Association recommends that patients with pancolitis undergo colonoscopy every 1–3 years beginning after 8 years of the disease. Suspicious lesions, such as strictures, polypoid lesions, and mucosal plaques, warrant biopsy. Random biopsies are also necessary because the colon cancer of ulcerative colitis does not always follow the sequence of polyp to cancer; it may also develop on a flat mucosal surface. If severe dysplasia is identified on biopsy, removal of the colon and rectum is indicated . Severe dysplasia is evident on several biopsies taken during a recent colonoscopy. Q: What surgical principles are important to consider with regard to the risk of cancer? A: Procedures that remove the entire colonic and rectal mucosa are curative , eliminating the risk of cancer. It is also desirable to restore anal continence and establish a reservoir function to allow defecation to occur at convenient times for the patient. In addition, it is necessary to use a procedure that accomplishes these goals in a highly reliable fashion with low operative risk . Q: What are the procedures for treating ulcerative colitis? A: Treatment of ulcerative colitis involves several procedures. In the past, total proctocolec- tomy and ileostomy was the approach of choice. Regardless of whether the patient had a continent ileostomy, no ileostomy was desirable, and normal defecation was preferable. Sub- total colectomy, mucosectomy (removal of the rectal mucosa), and ileorectal anastomosis, which is still sometimes indicated for older patients, then became the procedure of choice. Its failure rate is as high as 20%–50% after 5–10 years. SAMPLE