Patient information: Surgical treatment of Crohn's disease

CROHN'S DISEASE OVERVIEW

Crohn's disease is an inflammatory condition of the digestive tract that affects children and adults. Common features of Crohn's disease include mouth sores, diarrhea, abdominal pain, weight loss, and fever. Patients can also have problems outside of the digestive tract, including a skin rash, joint pain, eye redness, and, less commonly, liver problems.

Treatment of Crohn's disease is individualized and depends upon the area of the digestive tract affected, the type of symptoms, and the activity of the disease. Although efforts are aimed at controlling the disease with medications, the majority of patients (around 80 percent) ultimately require surgery.

Crohn's disease can potentially involve the entire gastrointestinal tract. It is a chronic, diffuse, recurring disease that is not curable by surgery. As a result, surgery is usually reserved for patients in whom a complication develops or for patients with symptoms that do not respond to medical therapy.

A full discussion of Crohn's disease and medical treatments is available separately. (See "Patient information: Crohn's disease".)

REASONS FOR CROHN'S DISEASE SURGERY

The major reasons that surgery might be considered for the treatment of Crohn's disease include:

• Obstruction (blockage) or perforation (a hole)
• Chronic disability and failure to respond to medical therapy

In some settings, surgery may be the most efficient means to restore health and improve quality of life. However, surgery does not cure Crohn's disease, and recurrent disease is common following surgery (see 'Crohn's disease recurrence after resection' below.

Surgery is generally considered when symptoms cannot be controlled with medicine or when the side effects of medicine are unbearable. It can also relieve other medical problems, including the following:

• Blockages in the bowel
• Perforations, or holes, that are created when ulcers penetrate the intestinal wall
• Severe bleeding
• Abscesses, or pockets of pus, that form when the contents of the bowels seep through the bowel wall
• Fistulas (abnormal passages that develop from the intestine to the skin or another organ)
• Anal abscesses, fistulas

CROHN'S DISEASE SURGICAL OPTIONS

The procedures used most often for Crohn's disease are resection and anastomosis, strictureplasty, and balloon dilation.

Resection and anastomosis — For this procedure, the surgeon removes the diseased part of the intestine (resection), then rejoins the two ends (anastomosis). The surgeon attempts to preserve as much of the intestines as possible by removing only the areas involved in disease. Following resection and anastomosis, most patients are still able to defecate as usual, through the anus.

In some cases, an ostomy is created to allow the diseased parts of the bowel to heal. An ostomy is a connection between the bowel and the abdominal wall, where a bag is attached to collect waste from the intestine (figure 1). In most cases, the ostomy is temporary, and may be reversed after some period of time. In other cases, a permanent ostomy is required as a result of extensive peri-anal fistulas or severe inflammation of the rectum.

The idea an ostomy can be frightening. The patient must learn to care for the ostomy, including skin care, fitting and emptying the bag that covers the ostomy, and adjusting to a new appearance and bowel habits. Most patients are cared for by an ostomy nurse specialist, who is expert in the care of persons with ostomies. With training, time, and support, it is possible to lead a normal life with an ostomy.

Strictureplasty — Strictureplasty is a procedure used to relieve bowel obstructions by widening the affected areas of the intestines. It is sometimes done at the same time as a resection. The procedure widens the bowel, making it easier for fecal matter to pass.

This procedure is well suited for people who continually have blockage in a particular part of their intestines and who are at risk for short bowel syndrome (having too little small intestine left to adequately digest food) due to previous resections. Results of this procedure are generally excellent. The risk of developing a fistula or another stricture is small.

Balloon dilation — This is another method of widening the bowel. For this procedure, the surgeon guides an uninflated balloon, which is attached to a long, thin tube, through the bowel. When the obstruction is located, the balloon is inflated, widening the narrowed intestine.

This procedure is newer and less is known about its long-term success or safety. It may be useful, however, for people who need to postpone anastomosis or strictureplasty. There is a significant risk of the bowel tearing, which should be considered before this technique is used.

CROHN'S DISEASE RECURRENCE AFTER RESECTION

Crohn's disease will recur in most patients following surgery. New symptoms related to the disease will develop in about 10 to 15 percent of people per year after surgery. However, some patients have prolonged periods of remission after surgery, lasting as long as 15 years.

Crohn's disease recurrence is more likely in patients who have severe disease. It is less likely in those who have disease confined to the colon. Such patients have only a 10 percent recurrence rate in the small intestine at 10 years. Some of the medications used to treat Crohn's disease may also reduce the risk of recurrence; thus most patients continue on medications following surgery.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: Crohn's disease
Patient information: Sulfasalazine and the 5-aminosalicylates

Professional Level Information:
Clinical manifestations of Crohn's disease in children and adolescents
Clinical manifestations, diagnosis and prognosis of Crohn's disease in adults
Colorectal cancer surveillance in inflammatory bowel disease
Definition of and risk factors for inflammatory bowel disease
Diagnosis of inflammatory bowel disease in children and adolescents
Endoscopic diagnosis of inflammatory bowel disease
Epidemiology and etiology of inflammatory bowel disease in children and adolescents
Epidemiology and genetic and environmental factors in inflammatory bowel disease in adults
Fertility, pregnancy, and nursing in inflammatory bowel disease
Hepatobiliary manifestations of inflammatory bowel disease
Immunomodulator therapy in Crohn's disease
Infliximab in Crohn's disease
Investigational therapies in the medical management of Crohn's disease
Medical management of Crohn's disease in adults
Metabolic bone disease in inflammatory bowel disease
Overview of the management of Crohn's disease in children and adolescents
Perianal complications of Crohn's disease
Pulmonary complications of inflammatory bowel disease
Skin and eye manifestations of inflammatory bowel disease
Sulfasalazine and 5-aminosalicylates in the treatment of inflammatory bowel disease
Surgical management of inflammatory bowel disease
Patient information: Sulfasalazine and the 5-aminosalicylates

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• National Library of Medicine

      (www.nlm.nih.gov/medlineplus/healthtopics.html)

• National Institute of Diabetes and Digestive and Kidney Diseases

      (www.niddk.nih.gov)

• The American Society of Colon and Rectal Surgeons

      (www.fascrs.org)

• The American Gastroenterological Association

      (www.gastro.org)

• The Crohn's and Colitis Foundation of America

      (www.ccfa.org)

Patient Support — There are a number of online forums where patients can find information and support from other people with similar conditions.

• About.com Crohn's Disease Forum

      (http://ibdcrohns.about.com/forum)

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