Diseases, Disorders information

Ileorectostomy is an operation we perform often for patients with colonic Crohn’s disease but in whom the rectum must be normal, or very minimally involved, and you can tell that by inflating air into the rectum and seeing if it blows up normally. If it doesn’t, then the surgeon would be anastomosing the small bowel to a rigid pipe of rectum, which is totally unacceptable for long term control of continence. There can be really no anal pathology either, and they can’t already have short bowel.

Here is our general experience with ileorectostomy for Crohn’s disease, in 80 patients and with a reasonable mortality, but in our thought process we figure a third, a third, a third. A third of the patients will go from a ileorectostomy to Brooke ileostomy at some point in their postoperative course. Another third will have their ileorectostomy in place but doing poorly; poor control, lots of stools and so forth. But only a third have a fully satisfactory, long term outcome with ileorectostomy for Crohn’s disease.

What about this change in intrarectal Crohn’s? Well in Crohn’s disease of the anus it is surprising how often this is misdiagnosed when patients come to us. It’s really pretty simple. If the patients have huge skin tags, fissures, big ulcers in the anal canal -often not uncomfortable – there is a blue discoloration, cyanotic hue to the perianal area. That they are stricturing, that as you do a digital you can barely get your finger in, it’s a circumferential stricture at the top of the anal canal, or they have fistulas in funny locations. I mean, it’s obvious that this patient … and they have the symptoms of internal inflammatory bowel disease, it’s obvious that they have Crohn’s disease of the anus. But it is not so obvious if the patients are completely symptom free, no obvious evidence of proximal involvement, but they do indeed have anal Crohn’s.

What are we doing today? Well, thanks to – at least at our institution – our gastroenterologists are aggressively treating patients with anal Crohn’s disease, and the role of the surgeon has changed a little bit. We are still draining abscesses, placing setons as drains through complex fistulas to keep them drained so that they don’t form abscesses, and we medicate – in this era of anti-TNF alpha – we medicate these people aggressively. We will take them back to the operating room as necessary and the goal is to dry up the perianum. I think if you watch the literature for the next several months and years, that I think this is a rational approach in patients – particularly in younger patients – before we even think about having to excise the perianum and the anus for perianal Crohn’s disease.

For gastroduodenal Crohn’s disease, which is indeed quite rare, the symptoms of pain, nausea, vomiting and weight loss with studies to confirm upper GI Crohn’s disease with complications, as you see here, in obstruction, fistula and hemorrhage. The surgery for gastroduodenal Crohn’s disease is fortunately rare but consists really of only bypass and strictureplasty. Resection is reserved for only the worst situations.

What about disease-free margins in small-bowel Crohn’s disease? Just briefly, there are studies that show with normal and disease margins no difference in the rate of cumulative recurrence rate over an eight year period of time. This was published many years ago now, in 1983. In work from our own institution we would say that gross residual disease, in the orange line, has a much higher rate of recurrence than in the overall group of patients without gross residual disease. So what our practice is – at least mine is – is to approach the patient with small-bowel Crohn’s disease, resect that to non-diseased margins and do the anastomosis. If indeed the pathologist tells us that the margin is involved, I’ll go back slightly again – maybe 2 or 3 more centimeters – and do the anastomosis at that level. But I will not resect and resect apparently normal bowel if the disease margin is … if the margin is microscopically diseased only. Perhaps I can answer questions about that in a few minutes.

What about strictureplasty? I think all of you have surgeons who are interested in doing strictureplasty on patients. The rationale for strictureplasty, at least in their minds, is shown here. That indeed the disease involves the whole intestine. It is obviously impossible to cure Crohn’s disease by mere excision alone, and all diseased bowel does not need excision. So if the main problems the patients are having are stenotic in nature, then these can be relieved usually without excising the bowel. In this slide I will show you pretty much the originators or the popularizers of this operation. He was Alexander Williams in a 1985 publication showing a complication rate of about 14% and a symptom recurrence rate of 40% in patients who underwent strictureplasty. The Fazio group published a large group of patients, and our group here at the bottom showing the same preoperative complication rate and only 20% of the patients having recurrent symptoms. So strictureplasty is a definite option for patients with stenotic complications of small-bowel Crohn’s disease.

Approach to acute pelvic pain with a positive pregnancy test

In a female patient of reproductive age, presenting with acute pelvic pain, the first distinction is whether the pain is pregnancy-related or non-pregnancy-related on the basis of a serum pregnancy test.
In the patient with acute pelvic pain associated with pregnancy, the next step is localization of the tissue responsible for the hCG production.
Transvaginal ultrasound should be performed to identify an intrauterine gestation. Ectopic pregnancy is characterized by a noncystic adnexal mass and fluid in the cul-de-sac.
If a gestational sac is not demonstrated on ultrasonography, the following possibilities exist:
Ectopic pregnancy
Very early intrauterine pregnancy not seen on ultrasound
Recent abortion
Management of patients when a gestational sac is not seen with a positive pregnancy test
Diagnostic laparoscopy is the most accurate and rapid method of establishing or excluding the diagnosis of ectopic pregnancy.
Examination of endometrial tissue. For pregnant patients desiring termination, and for those patients in whom it can be demonstrated that the pregnancy is nonviable, suction curettage with immediate histologic examination of the curettings is a diagnostic option. The presence of chorionic villi confirms the diagnosis of intrauterine pregnancy, whereas the absence of such villi indicates ectopic pregnancy.

Management of the ectopic gestation

Two IV catheters of at least 18 gauge should be placed and 1-2 L of normal saline infused.
Laparoscopy or laparotomy with linear salpingostomy or salpingectomy should be accomplished in unstable patients. An HCG level should be checked in one week to assure that it is declining.
Methotrexate. Stable patients can be treated with methotrexate in a single intramuscular dose of 50 mg per meter2. Treatment response should be assessed by serial HCG measurements made until the hormone is undetectable.

Approach to acute pelvic pain in non-pregnant patients with a negative HCG
Acute PID is the leading diagnostic consideration in patients with acute pelvic pain unrelated to pregnancy. The pain is usually bilateral, but may be unilateral in 10%. Cervical motion tenderness, fever, and cervical discharge are common findings.
Acute appendicitis should be considered in all patients presenting with acute pelvic pain and a negative pregnancy test. Appendicitis is characterized by leukocytosis and a history of a few hours of periumbilical pain followed by migration of the pain to the right lower quadrant. Neutrophilia occurs in 75%. A slight fever exceeding 37.3EC, nausea, vomiting, anorexia, and rebound tenderness may be present.
Torsion of the adnexa usually causes unilateral pain, but pain can be bilateral in 25%. Intense, progressive pain combined with a tense, tender adnexal mass is characteristic. There is often a history of repetitive, transitory pain. Pelvic sonography often confirms the diagnosis. Laparoscopic diagnosis and surgical intervention are indicated.
Ruptured or hemorrhagic corpus luteal cyst usually causes bilateral pain, but it can cause unilateral tenderness in 35%. Ultrasound aids in diagnosis.
Endometriosis usually causes chronic or recurrent pain, but it can occasionally cause acute pelvic pain. There usually is a history of dysmenorrhea and deep dyspareunia. Pelvic exam reveals fixed uterine retrodisplacement and tender uterosacral and cul-de-sac nodularity. Laparoscopy confirms the diagnosis

Clinical evaluation
Assessment of acute pelvic pain should determine the patient’s age, obstetrical history, menstrual history, characteristics of pain onset, duration, and palliative or aggravating factors.
Associated symptoms may include urinary or gastrointestinal symptoms, fever, abnormal bleeding, or vaginal discharge.
Past medical history. Contraceptive history, surgical history, gynecologic history, history of pelvic inflammatory disease, ectopic pregnancy, sexually transmitted diseases should be determined. Current sexual activity and practices should be assessed.
Method of contraception
Sexual abstinence in the months preceding the onset of pain lessons the likelihood of pregnancy-related etiologies.
The risk of acute PID is reduced by 50% in patients taking oral contraceptives or using a barrier method of contraception. Patients taking oral contraceptives are at decreased risk for an ectopic pregnancy or ovarian cysts.
Risk factors for acute pelvic inflammatory disease. Age between 15-25 years, sexual partner with symptoms of urethritis, prior history of PID.

Physical examination
Fever, abdominal or pelvic tenderness, and peritoneal signs should be sought.
Vaginal discharge, cervical erythema and discharge, cervical and uterine motion tenderness, or adnexal masses or tenderness should be noted.

Laboratory tests
Pregnancy testing will identify pregnancy-related causes of pelvic pain. Serum beta-HCG becomes positive 7 days after conception. A negative test virtually excludes ectopic pregnancy.
Complete blood count. Leukocytosis suggest an inflammatory process; however, a normal white blood count occurs in 56% of patients with PID and 37% of patients with appendicitis.
Urinalysis. The finding of pyuria suggests urinary tract infection. Pyuria can also occur with an inflamed appendix or from contamination of the urine by vaginal discharge.
Testing for Neisseria gonorrhoeae and Chlamydia trachomatis are necessary if PID is a possibility.
Pelvic ultrasonography is of value in excluding the diagnosis of an ectopic pregnancy by demonstrating an intrauterine gestation. Sonography may reveal acute PID, torsion of the adnexa, or acute appendicitis.
Diagnostic laparoscopy is indicated when acute pelvic pain has an unclear diagnosis despite comprehensive evaluation.

Differential diagnosis of acute pelvic pain
Pregnancy-related causes. Ectopic pregnancy, spontaneous, threatened or incomplete abortion, intrauterine pregnancy with corpus luteum bleeding.
Gynecologic disorders. PID, endometriosis, ovarian cyst hemorrhage or rupture, adnexal torsion, Mittelschmerz, uterine leiomyoma torsion, primary dysmenorrhea, tumor.
Nonreproductive tract causes
Gastrointestinal. Appendicitis, inflammatory bowel disease, mesenteric adenitis, irritable bowel syndrome, diverticulitis.
Urinary tract. Urinary tract infection, renal calculus.