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March 2011 IBD Newsletter >>
Clinical Scenario: Crohn’s Disease
A 32-year-old female was initially diagnosed with Crohn’s disease at age 28 and underwent an urgent appendectomy for presumed appendicitis. Though she was treated medically for two years, she eventually required an ileocolic resection due to worsening symptoms of small bowel obstruction. At the time of her surgery, along with a significant ileal stricture, she was noted to have a distal enteroenteric fistula requiring resection of 1.5 feet of distal ileum and proximal cecum. She has since been maintained on medical therapy including Mercapto-purine. Unfortunately, within one year of her surgery she is again experiencing intermittent obstructive symptoms.
CT enterography demonstrated significant stricturing near the prior anastomosis. Colonoscopy demonstrated patchy erythema of the distal sigmoid colon and a strictured ileocolic anastomosis that could not be passed. Further medical management was not beneficial and her symptoms worsened. She returned to the operating room for exploration. This revealed a thickened prior ileocolic anastomosis with stricture involving 12 inches. In addition, an apparent early fistula was noted between this segment and the sigmoid colon. Finally, two palpable short strictures were noted 2 and 3 feet proximal to the thickened ileum.
This patient clearly has evidence of more aggressive disease, both with her early symptomatic recurrence and involvement of multiple areas of the small bowel. With this in mind consideration must be given to maximize her small bowel length as it is likely that her disease will progress. Though she is not at immediate risk of short gut, a resection involving all grossly visible disease in this case would put her at risk.
The most appropriate option in this case would be to perform a resection of the prior ileocolic anastomosis with primary ileocolic re-anastomosis and primary closure of the evolving sigmoid fistula. In addition, the upstream strictures must be addressed. Though these could be additionally resected, the concern for maintaining future small bowel length makes strictureplasty a better option.
In this case, two strictureplasties can be performed, thus preserving all proximal bowel. Further assessment of other occult strictures can also be assessed at this time with careful passage of a Foley catheter through the bowel lumen. Aggressive postoperative medical management will be necessary for this patient due to her risk of recurrent disease.
For more clinical information on Crohn’s disease, please click here.