AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Multimedia
• References

Crohn disease is a chronic disease that primarily affects young individuals. Although its etiology is unknown, recent findings regarding the genetic and immunologic features of Crohn disease have provided insight into the possible mechanisms of pathogenesis. Corticosteroids have been the mainstay of medical treatment in patients with active inflammation, but salicylates, antibiotics, and immunosuppressants have also shown benefit. Biologic therapies involving antibodies, antisense oligonucleotides, and cytokines are promising new medical therapies. Surgical treatment has been reserved for refractory disease and complications. Minimally invasive surgery has provided an alternative to the traditional open surgical approach.

History of the Procedure

In 1932, the article "Regional Ileitis" by Crohn, Ginzburn, and Oppenheimer appeared in the Journal of the American Medical Association. This landmark article described findings in a series of 14 patients with a disease of the terminal ileum characterized by subacute or chronic necrotizing and cicatrizing inflammation. Since then, Crohn disease has been found to occur in all parts of the gastrointestinal tract and to have widespread extraintestinal manifestations. The pathologic criteria to distinguish Crohn disease from other forms of inflammatory bowel disease were not established until 1960.

Problem

Crohn disease predominantly affects a young population and is a chronic incurable condition. It requires ongoing medical management and causes long-term pain and disability. Frequent surgical interventions are often required to treat complications. The understanding of this disease in incomplete, but advances in medical therapies and surgical techniques have led to an improvement in patients' quality of life.

Frequency

The incidence of Crohn disease in the general population is approximately 5.3 cases per 100,000 persons. The onset of the disease peaks in older adolescents and young adults. However, approximately 5% of new cases occur in children younger than 5 years. Crohn disease affects persons of every ethnic origin, but it is most common in the Ashkenazi Jewish and Caucasian populations. Male and female individuals are affected with equal frequency.

Etiology

The etiology of Crohn disease is unknown. Its pathogenesis is likely multifactorial, involving a combination of infectious agents and environmental exposures that activate an immune response in a genetically susceptible host. Familial clustering of Crohn disease suggests a genetic etiology. A positive family history is found in 10-15% of patients. The relative risk for first-degree relatives of these patients is estimated to be 10-21 times that of the general population. Disease locations and types (eg, stricturing, inflammatory, perforating) tend to be similar among family members. Other genetic abnormalities linked with Crohn disease include hereditary conditions such as glycogen storage disease type 1b and dysfunction of the complement pathway.

Bacterial agents have long been thought to be involved in the pathogenesis of Crohn disease, though no bacteria have been definitively identified. Therefore, in the multifactorial model, the interaction of bacteria, immune mechanisms, and genetic susceptibility may be necessary for the development of the disease.

Environmental factors, such as smoking and exposure to second-hand smoke, have been linked to Crohn disease. Concerns about the measles vaccine in the development of Crohn disease have been unfounded. Although appendectomy has been suggested to be protective in ulcerative colitis, it is not a protective in Crohn disease.

Pathophysiology

Crohn disease can affect any part of the alimentary tract from the mouth to the anus. The most common site is the terminal ileum. The appendix is often involved as well. The disease is often segmental (unlike ulcerative colitis), and the rectum is frequently spared.

On endoscopy, Crohn disease typically appears as patchy areas of inflammation separated by uninvolved bowel. The earliest lesions are aphthous ulcers, ie, tiny, discrete erosions that typically occur over lymphoid follicles. As the disease progresses, interconnecting rows of aphthous ulcers create linear ulcers. These linear ulcers cross transverse folds, contributing to a cobblestone appearance.

On gross examination, surgical specimens are rigid and thickened as a result of chronic inflammation and fibrosis during healing periods. The mesentery is typically thickened and foreshortened and may partly surround the bowel wall in a phenomenon known as creeping fat (see Image 1). The transmural nature of inflammation contributes to possible fistulous connections between segments of bowel or other organs.

Clinical

The differential diagnosis of Crohn disease includes infections, such as bacterial enteritis, giardiasis, amoebiasis, viral gastroenteritis, and granulomatous disease, or other inflammatory conditions, such as ulcerative colitis.

Crohn disease most commonly presents in an adolescent or young adult with chronic abdominal pain, diarrhea, and weight loss. Patients presenting with Crohn colitis may additionally have bloody diarrhea, tenesmus, or incontinence. A small group of children initially present for treatment because of secondary amenorrhea or a delayed onset of puberty.

Approximately 5% of patients present with only perianal symptoms. Anal fissures are the most common finding in perianal disease. They are often located eccentrically rather than in the classic posterior midline position of most benign fissures. Skin tags, anal stenosis, fecal incontinence, fistula, and perianal abscesses are also common signs and symptoms of perianal disease.

On occasion, a patient's initial presentation is for the treatment of a complication of Crohn disease. Although more common in ulcerative colitis, toxic megacolon can be a life-threatening manifestation of Crohn disease. Small-bowel obstruction, intestinal perforation, intra-abdominal abscess, or enteric fistulas can also be part of the initial presentation. Because symptoms of ileitis may mimic those of appendicitis, the diagnosis may be made at the time of appendectomy.

Of interest, extraintestinal manifestations of Crohn disease may develop first. Many of these extraintestinal signs overlap with those of ulcerative colitis. Aphthous ulcerations of the buccal mucosa, lips, or tongue should alert the clinician to assess for intestinal involvement. Skin manifestations, such as erythema nodosum and pyoderma gangrenosum, occur more commonly in Crohn disease then in ulcerative colitis. These occur predominantly on the lower legs over the tibia.

Ankylosing spondylitis is more common in men with Crohn disease than in women. Ocular symptoms, such as iritis and uveitis, and hepatic involvement with chronic hepatitis or sclerosing cholangitis may be observed, though these are most commonly associated with ulcerative colitis than with Crohn disease. Renal calculi and cholelithiasis are complications of long-standing ileal disease.

Children commonly have growth failure as an extraintestinal manifestation of inflammatory bowel disease. This growth failure results from both decreased caloric intake and circulating inflammatory cytokines. Growth failure is defined by using several parameters, including height below the third percentile, a shift to a lower height percentile, or reduced growth velocity. Enteral feeding is the first-line treatment. However, achieving remission of the inflammation is critical to maintaining growth. If intensive medical treatment does not result in remission, surgical intervention may be warranted, particularly for isolated small-bowel disease.

INDICATIONS

Section 3 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Multimedia
• References

Because Crohn disease cannot be cured with surgical intervention, the goal is palliation of active symptoms and disease remission. Indications for surgery include intractable disease, growth retardation, cancer, perianal disease, and complications of intestinal disease, such as stricture, intestinal obstruction, and enteric, colonic, or vesicular fistulas. In children with recurrent acute episodes, the potential for further bowel loss must be weighed against the risks of long-term steroid therapy and failure to thrive.

Indications for surgical intervention in patients with Crohn disease can be summarized as follows:

• Failure of medical therapy
• Complications of steroid or other medical therapy (eg, growth failure)
• Complications of the disease process
• • Intestinal obstruction (especially of the terminal ileum)
  • Intestinal perforation
  • Intestinal bleeding
  • Recalcitrant sepsis

RELEVANT ANATOMY

Section 4 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Multimedia
• References

See Pathophysiology.

CONTRAINDICATIONS

Section 5 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Multimedia
• References

The operative management of Crohn disease remains one of the most challenging areas of surgery. Surgery is generally reserved for refractory disease or intestinal complications. Resection of asymptomatic disease is not warranted because disease recurrence is the rule.

Although surgical options are expanding, Crohn disease is an important contraindication for creation of a Kock pouch. Patients with Crohn disease who receive a Kock pouch ultimately require resection of the pouch or continuing treatment for severe pouchitis.

WORKUP

Section 6 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Multimedia
• References

Lab Studies

• Stool specimens are sent for an investigation of possible infectious causes for the patient's symptoms.
• Laboratory examinations may demonstrate manifestations of the disease, such as anemia of chronic disease, evidence of malnutrition, or an increased sedimentation rate or C-reactive protein level.
• A complete blood cell count may show anemia caused by iron, vitamin B12, or folic acid deficiency.
• Albumin and prealbumin levels reflect levels of nutrition. Deficiencies of trace elements such as zinc, selenium, and copper are common.
• Electrolyte analysis, with a determination of calcium and magnesium levels, can help in assessing level of hydration, renal function, and malabsorption.
• Fat malabsorption may lead to decreased levels of the fat-soluble vitamins. Therefore, prothrombin times and vitamin A and vitamin D levels may be assessed.
• Results of liver function tests may be elevated transiently because of inflammation or chronically because of sclerosing cholangitis.
• Amylase and lipase levels may be elevated because of drug-induced pancreatitis. Azathioprine, 6-mercaptopurine, and 5-aminosalacylic acid can all cause pancreatitis.

Imaging Studies

• CT scanning should be the first radiologic procedure performed in patients with acute inflammatory symptoms (see Image 4).
• CT scanning may show bowel-wall thickening, mesenteric edema, abscesses, or fistulas.
• Small-bowel contrast-enhanced and enteroclysis studies may be valuable in demonstrating the distribution of small bowel disease (see Image 5). Mucosal fissures, bowel fistulas, strictures, and obstructions can be visualized. The terminal ileum may be narrowed and thickened, with a characteristic pipe appearance
• In recent studies, MRI had high sensitivity and specificity for both the diagnosis of Crohn disease and the assessment of severity compared with the criterion standard of ileocolonoscopy.

Diagnostic Procedures

• Endoscopic visualization and biopsy are essential in the diagnosis of Crohn disease
• Colonoscopy with intubation of the terminal ileum is used to evaluate the extent of disease, to demonstrate strictures and fistulas, and to obtain biopsy samples to differentiate this process from other inflammatory conditions.
• Given the increased risk of colorectal cancer in patients with inflammatory bowel disease, colonoscopy may have a role in cancer surveillance, though this practice remains controversial.
• Upper-gastrointestinal endoscopy may be used to diagnose gastroduodenal disease. It is recommended for all children regardless of the presence or absence of upper-gastrointestinal symptoms.
• Despite extensive workup, 10% of patients with isolated Crohn colitis have an indeterminate colitis with features of both Crohn disease and ulcerative colitis. If these patients undergo long-term follow-up, small-bowel disease characteristic of Crohn disease ultimately develops.

Histologic Findings

Crohn disease is microscopically characterized by transmural inflammation of all layers of the bowel wall. In the mucosa, cryptitis, crypt abscesses, basal plasmacytosis, and crypt ulcers are commonly observed. Noncaseating granulomas in the bowel wall are characteristic but not pathognomonic of Crohn disease. Proliferative stromal and nodular inflammatory changes occur in the bowel wall, leading to a thick, firm appearance and, ultimately, strictures.

TREATMENT

Section 7 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Multimedia
• References

Medical therapy

Treatment strategies for patients with Crohn disease consist of attempts at medical remission and supportive medical management of chronic symptoms and exacerbations. Surgery is reserved for complications of intestinal disease or cases in which medical management is unsuccessful. Numerous medications are available to control acute inflammatory symptoms and prevent recurrence of intestinal disease. Although numerous studies regarding postoperative prophylactic therapy have been performed in adults, no prospective studies have been conducted in children. Nutritional therapies are focused on preventing the weight loss and malnutrition that frequently accompany the disease.

Aminosalicylates

Oral and topical salicylates are often first-line medications in the treatment of acute exacerbations of Crohn disease. Sulfasalazine was the first salicylate to be used in inflammatory bowel disease. It consists of a sulfapyridine moiety (the carrier compound) linked to 5-aminosalicylic acid (the active ingredient). After reaching the colon, sulfapyridine is released from the 5-aminosalicylic acid by means of colonic bacteria. The salicylate compound acts locally to prevent inflammation by inhibiting various elements of the inflammatory cascade. Sulfasalazine is effective in active ileocolonic and colonic disease but less effective in isolated small-bowel disease. It is often helpful in preventing recurrence after surgery to treat active disease.

Numerous adverse effects, including gastrointestinal symptoms (eg, nausea, vomiting, abdominal pain) are associated with the sulfapyridine moiety and limit patients' tolerance of this medication. Newer oral compounds, such as mesalamine (Asacol, Pentasa), olsalazine (Dipentum), and balsalazide (Colazal), lack the sulfapyridine carrier; they are better tolerated than sulfapyridine. In addition, topical aminosalicylates in the form of suppositories and enemas may be of benefit in patients with distal colonic Crohn disease.

Corticosteroids

Glucocorticoids have long been known to be highly effective in the treatment of acute episodes of Crohn disease. They induce remission in all disease locations. However, long-term corticosteroid treatment does not have a role in maintaining remission in patients with quiescent disease or in management after medical or surgical treatment of active disease. High-dose systemic steroids may be administered for weeks to months as treatment of active disease.

Corticosteroids have many adverse effects, including the development of cushingoid features, hypertension, hyperglycemia, cataracts, osteoporosis, osteonecrosis, and psychological effects. In children, growth retardation, delayed onset of puberty, and delayed bone maturation are particular concerns related to repeated steroid treatments. Newer steroids, such as budesonides, are rapidly metabolized during their first pass through the liver; therefore, their potential for adverse effects is limited. Topical steroid enemas may be used in distal Crohn colitis without the systemic effects.

Antibiotics

Enteric bacteria may promote intestinal inflammation, and antibiotics aimed at the intestinal flora have been successfully used in both intestinal and perianal Crohn disease. Metronidazole is most widely used in perianal Crohn disease; it can promote complete healing of perianal fistulas. If administered after ileal resection, metronidazole can effectively decrease postsurgical disease recurrence, as shown in randomized trials. However, symptoms often recur after the drug is stopped, and adverse effects often limit its use. Ciprofloxacin or other broad-spectrum antibiotics may be used as alternatives, with similar effectiveness.

Immunosuppressants

Azathioprine and its metabolite, 6-mercaptopurine, are inhibitors of purine synthesis. They are used in the treatment of both active and quiescent Crohn disease. In a randomized controlled trial, mercaptopurine offered significant benefit in the treatment of active disease and disease with fistulas. Moreover, azathioprine and 6-mercaptopurine therapies allow for early reduction and cessation of corticosteroid treatment during acute episodes. Unlike salicylates and steroids, the immunosuppressants are effective as maintenance therapies for quiescent disease. Several months of treatment are usually required in order to achieve an effect. The optimal duration of therapy remains unclear.

Dose-dependent adverse effects include nausea, rash, marrow toxicity, hepatitis, and acute pancreatitis. Although no evidence suggests an increased risk of solid tumors in adults, concerns about lymphoreticular malignancies have limited the use of these medications in children.

Cyclosporine is commonly used as an immunosuppressant with organ transplantation. In a randomized prospective trial, high-dose oral cyclosporine was effective in the treatment of active Crohn disease. Its rapid onset of action (<2 wk) makes it an attractive bridge therapy until azathioprine or 6-mercaptopurine become effective. The effects of cyclosporine continue for several months after cessation of its administration. Nephrotoxicity, hypertension, electrolyte abnormalities, gingival hyperplasia, and paresthesias are the most common adverse effects.

Alternative immunosuppressants such as tacrolimus (FK-506) and mycophenolate mofetil are being explored as treatments for Crohn disease. Preliminary data suggest that these treatments have some benefit in patients with severe inflammatory bowel disease.

Biologic therapies

Tumor necrosis factor-alpha (TNF-alpha) is an inflammatory cytokine that acts as a primary mediator of intestinal inflammation and injury in inflammatory bowel disease. Preliminary evidence from clinical trials involving antibodies against TNF-alpha has shown promise in the treatment of patients with active and quiescent disease.

Approved by the US Food and Drug Administration (FDA) in 1998, infliximab is a chimeric antibody that specifically targets TNF-alpha. Data from noncontrolled studies suggest an improvement in the endoscopic and histologic appearance of chronic active disease after a single infusion of infliximab. A benefit has also been observed in refractory enterocutaneous and perianal fistulae.

CDP571 is a human monoclonal anti-TNF-alpha antibody that may be advantageous in patients with refractory Crohn disease. Other potential therapies being evaluated include thalidomide, antisense oligonucleotides against intercellular adhesion molecule-1, recombinant interleukin-10 and interleukin-11, and anti-CD4 antibodies.

Nutritional therapy

Although ineffective as a primary therapy, nutritional manipulations, which allow the bowel rest, can be effective adjuncts in the treatment of active Crohn disease. Both parenteral and enteral nutrition are effective. However, because of the associated risks and costs of parenteral nutrition, it is typically reserved for the postoperative period. Enteral nutrition has the benefit of altering the bacterial flora and providing direct nourishment to the intestinal mucosa. The effectiveness of enteral nutrition in active disease was shown in several randomized trials. However, relapse commonly occurs after the cessation of enteral feeding. Supplemental enteral nutrition at night without dietary restrictions during the day is beneficial in maintaining disease remission. To the authors' knowledge, no benefit of elemental diets compared with conventional enteral nutrition has been shown.

Surgical therapy

Most patients with Crohn disease require surgical intervention during their lifetime. Unlike ulcerative colitis, Crohn disease has no surgical cure. Within 20 years of the onset of symptoms, 80% of patients with Crohn disease require surgery, and many require multiple procedures. About 20-30% of patients have a recurrence of disease within the first postoperative year. Hence, every attempt at conserving the small bowel should be made in the surgical approach to Crohn disease. Despite this approach, repeated intestinal resection for Crohn disease is a major cause of short-bowel syndrome.

The most common complication of Crohn disease is small-bowel obstruction, which occurs in 30-50% of patients. The obstruction is typically due to intestinal strictures from repeated bouts of inflammation and subsequent fibrosis. In the case of a complete obstruction or a partial obstruction refractory to nonsurgical management, surgical intervention is required. Surgical options for intestinal strictures include resection of the strictured bowel or stricturoplasty. In cases of long strictures (>12 cm) or multiple strictures in close proximity, surgical resection with primary anastomosis is often required.

Stricturoplasty for multiple short strictures has the benefit of bowel conservation. A Foley catheter (inflated to 25 mm) can be passed through the lumen to detect additional distal strictures. The strictured bowel is incised longitudinally to a point 1-2 cm beyond the narrowing and then closed transversely without resection. For long or multiple confluent strictures, a stricturoplasty that resembles a Finney side-to-side pyloroplasty can be used to conserve bowel length. Hydrostatic balloon dilatation of ileocolic strictures has been performed, but its effects may not be long-lasting. Bypass procedures are usually reserved for duodenal obstructions.

Other complications of Crohn disease that may require surgical intervention include free perforation, abscesses, fistulas, toxic megacolon, and massive hemorrhage. More than 10% of patients with Crohn disease have an intra-abdominal or pelvic abscess during their lifetime. Abscesses must be drained either surgically or percutaneously. Although surgical drainage is most often successful, an attempt at percutaneous drainage may spare some patients an operation.

Because of the transmural nature of the inflammation, fistula formation is common. Enteroenteric, enterocutaneous, enterovesical, and rectovaginal fistulas may often be initially treated using the principles of fistula healing and medical therapy. If medical therapy is unsuccessful, resection of the involved bowel is required in symptomatic patients.

Toxic megacolon and massive hemorrhage are uncommon complications of Crohn disease. However, they may require urgent bowel resection. Total abdominal colectomy with a Hartmann pouch has been advocated for fulminant toxic megacolon. This allows future restoration of bowel continuity with a sphincter-preserving ileorectal anastomosis. However, a permanent ileostomy may ultimately be required due to recurrent rectal disease.

Perianal Crohn disease presents a particularly difficult management challenge. Fissures, fistulas, and abscess may be multiple and recurrent, and repeat operations may lead to sphincter damage and incontinence. True abscess require drainage. When a fistula tract can be identified, a silicone Seton can be used to prevent premature skin closure and recurrent abscesses. These indwelling Setons should be left in place for at least 12 months to allow complete epithelialization of the tract. This approach leads to a chronically draining fistula tract. In patients in whom severe perianal disease has destroyed the sphincter, proctectomy with permanent ileostomy may be necessary.

Laparoscopic resection

The laparoscopic approach to Crohn disease has been shown to be feasible as well as safe. Complications of Crohn disease such as abscesses, phlegmons, and recurrent disease have been safely treated laparoscopically and are not contraindications to laparoscopy in these patients.

Although many surgeons still perform open resection and though it should be considered the criterion standard, the laparoscopic approach is being used with increasing frequency. In children, laparoscopic intestinal resections have usually been reserved for proctectomy and pull-through procedures in Hirschsprung disease. Segmental intestinal resections in Crohn disease can easily be accomplished as well. No difference in recurrence rates are found in adults undergoing laparoscopic versus open ileocolic resection. To this authors' knowledge, no data have been published regarding recurrence rates in children undergoing open versus laparoscopic resection.

Over a 5-year period at Children's Mercy Hospital, 18 patients underwent laparoscopic segmental resection of the terminal ileum and cecum with primary anastomosis of the ileum to the colon.

Surgical technique

After the patient is given general endotracheal anesthesia and after a urinary catheter is introduced, the abdomen is prepared and draped widely. A 12-mm incision is made in the umbilicus through which a 12-mm cannula is introduced for future insertion of the endoscopic stapling device. Two 5-mm incisions are made, 1 in the left mid-abdomen and 1 in the left suprapubic region; through these, grasping forceps are inserted for retraction.

The final port is initially 5 or 10 mm long and is placed in the right lower abdomen in a location similar to that used for open appendectomy incision. This incision is subsequently enlarged to approximately 2 cm, and the specimen is extracted from the abdominal cavity through this incision (see Image 2). In addition, the 2 ends of the intestine to be anastomosed are exteriorized through this incision and a 2-layer extracorporeal anastomosis is created.

The first step in the operation is ligation and division of the proximal ileum with the endoscopic stapler. Next, with either an ultrasound-activated scalpel (UltraCision Harmonic Scalpel; Ethicon Endosurgery, Cincinnati, OH) or sealing device (Ligasure; Valley Lab, Boulder, CO), the mesentery of the proximal right colon is coagulated and transected (see Image 3). Then, the right lower abdominal incision is enlarged to 2 cm, and the specimen is exteriorized. With this technique, the distal margin of resection is most precisely determined, and the distal resection margin can be divided with the surgical stapler. This procedure may also be performed intracorporeally with an endoscopic stapler.

Once the resected specimen is removed, the proximal small intestine is delivered through the right lower abdominal incision and a 2-layer extracorporeal anastomosis is created between the proximal and distal margins. The bowel is then returned to the abdominal cavity, and all incisions are closed.

In the limited experience at Children's Mercy Hospital, all patients were discharged home on either the fourth or fifth postoperative day. Nasogastric tubes were not placed to improve the patients' comfort during postoperative convalescence. No intraoperative or postoperative complications have developed in these patients.

Preoperative details

A recent evaluation of the extent of intestinal disease with appropriate radiologic and endoscopic studies is essential. Steroids are tapered as much as tolerated, and the patient's nutritional status is optimized.

Thorough bowel cleansing is required in patients without intestinal obstruction. As an alternatively, patients with partial chronic obstructions for whom bowel preparation is unsafe can drink clear liquids for several days.

In patients who may receive stomas, preoperative counseling best prepares the patients and their families. A stomal therapist should be involved with the patient's care before surgery. Patients should also be counseled about their expectations for surgery because future recurrences are likely.

Intraoperative details

Most patients will have recently received corticosteroids. Therefore, perioperative steroid dosing is likely to be required.

Perianal, rectal, and sigmoidoscopic examinations are often performed while the patient is under anesthesia to determine the presence and extent of perianal disease.

The goal of surgical resection is to remove the grossly involved bowel; microscopic disease at the resection margins is acceptable. Primary anastomosis of bowel can usually be achieved. On occasion, a proximal functioning stoma or Brooke ileostomy is required in patients in whom an anastomosis is unsafe.

Postoperative details

After surgery, steroids are appropriately tapered. Patients who were receiving a low-dose or short-term steroid before surgery may be treated with a relatively rapid taper. Parenteral nutrition is often continued until bowel function returns.

COMPLICATIONS

Section 8 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Multimedia
• References

The most common complications of surgery for Crohn disease are intraperitoneal adhesions. Patients with Crohn disease who are undergoing abdominal surgery are also at increased risk for developing enterocutaneous fistulas as a result of surgery.

OUTCOME AND PROGNOSIS

Section 9 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Multimedia
• References

Crohn disease is a chronic, incurable condition. Among children with juvenile-onset Crohn disease, 86% require surgical intervention with 15 years of disease onset. Although our understanding of the disease is incomplete, advances in medical therapies and surgical procedures have led to additional treatment options for patients. With proper treatment, most achieve a healthy height and weight, and the mortality rate for the disease is low.

MULTIMEDIA

Section 10 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Multimedia
• References

Media file 1:  Laparoscopic view depicts creeping fat along the mesentery of the terminal ileum.
	View Full Size Image
Media type:  Photo

Media file 2:  Postoperative photograph depicts the incisions used for laparoscopic ileocolectomy in a 14-year-old male adolescent with obstruction of the terminal ileum. Note the 2-cm incision in the right lower abdomen through which the specimen was extracted and the extracorporeal anastomosis performed. The 12-mm umbilical incision is nicely hidden in the depths of the umbilicus. A 5-mm incision is visible in the left lower abdomen, and another is in the left suprapubic region just above the top of the pants.
	View Full Size Image
Media type:  Photo

Media file 3:  On this laparoscopic photograph, the mesentery of the terminal ileum is being coagulated with a sealing device (Ligasure; Valley Lab, Boulder, CO). Note that the ligation of the mesentery proceeds near the border of the ileum rather than at the base of the mesentery.
	View Full Size Image
Media type:  Photo

Media file 4:  CT scan in a patient with terminal ileal Crohn disease shows an enteroenteral fistula (arrow) between loops of diseased small intestine.
	View Full Size Image
Media type:  CT

Media file 5:  A teenaged patient with Crohn disease underwent a contrast-enhanced upper-GI study with small-bowel follow-through. Several loops of small bowel are in the pelvis. Note 1 loop of distal bowel with a thickened wall (solid arrow), which is contrasted with a less involved loop of bowel in which the intestinal wall is not thickened at all (dotted arrow).
	View Full Size Image
Media type:  MRI

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Multimedia
• References

• Aleali M, Milsom JW. Laparoscopic surgery in Crohn''s disease. Surg Clin North Am. Feb 2001;81(1):217-30, x. [Medline].
• Aufses AH Jr. The history of Crohn''s disease. Surg Clin North Am. Feb 2001;81(1):1-11, vii. [Medline].
• Bernstein CN, Blanchard JF, Rawsthorne P, Yu N. The prevalence of extraintestinal diseases in inflammatory bowel disease: a population-based study. Am J Gastroenterol. Apr 2001;96(4):1116-22. [Medline].
• Bernstein LH, Frank MS, Brandt LJ, Boley SJ. Healing of perineal Crohn''s disease with metronidazole. Gastroenterology. Sep 1980;79(3):599. [Medline].
• Bond JH. Colorectal cancer update. Prevention, screening, treatment, and surveillance for high-risk groups. Med Clin North Am. Sep 2000;84(5):1163-82, viii. [Medline].
• Brynskov J, Freund L, Rasmussen SN, et al. A placebo-controlled, double-blind, randomized trial of cyclosporine therapy in active chronic Crohn''s disease. N Engl J Med. Sep 28 1989;321(13):845-50. [Medline].
• Chen HH, Wexner SD, Iroatulam AJ, et al. Laparoscopic colectomy compares favorably with colectomy by laparotomy for reduction of postoperative ileus. Dis Colon Rectum. Jan 2000;43(1):61-5. [Medline].
• Church JM. Molecular genetics and Crohn''s disease. Surg Clin North Am. Feb 2001;81(1):31-8, vii-viii. [Medline].
• Couckuyt H, Gevers AM, Coremans G, et al. Efficacy and safety of hydrostatic balloon dilatation of ileocolonic Crohn''s strictures: a prospective long-term analysis. Gut. Apr 1995;36(4):577-80. [Medline].
• D''haens G, Van Deventer S, Van Hogezand R, et al. Endoscopic and histological healing with infliximab anti-tumor necrosis factor antibodies in Crohn''s disease: A European multicenter trial. Gastroenterology. May 1999;116(5):1029-34. [Medline].
• Davis RL, Kramarz P, Bohlke K, et al. Measles-mumps-rubella and other measles-containing vaccines do not increase the risk for inflammatory bowel disease: a case-control study from the Vaccine Safety Datalink project. Arch Pediatr Adolesc Med. Mar 2001;155(3):354-9. [Medline].
• Ewe K, Herfarth C, Malchow H, Jesdinsky HJ. Postoperative recurrence of Crohn''s disease in relation to radicality of operation and sulfasalazine prophylaxis: a multicenter trial. Digestion. 1989;42(4):224-32. [Medline].
• Fellermann K, Ludwig D, Stahl M, et al. Steroid-unresponsive acute attacks of inflammatory bowel disease: immunomodulation by tacrolimus (FK506). Am J Gastroenterol. Oct 1998;93(10):1860-6. [Medline].
• Florie J, Horsthuis K, Hommes DW, et al. Magnetic resonance imaging compared with ileocolonoscopy in evaluating disease severity in Crohn's disease. Clin Gastroenterol Hepatol. Dec 2005;3(12):1221-8. [Medline].
• Garcia JC, Persky SE, Bonis PA, Topazian M. Abscesses in Crohn''s disease: outcome of medical versus surgical treatment. J Clin Gastroenterol. May-Jun 2001;32(5):409-12. [Medline].
• Gavin J, Anderson CE, Bremner AR, Beattie RM. Energy intakes of children with Crohn's disease treated with enteral nutrition as primary therapy. J Hum Nutr Diet. Oct 2005;18(5):337-42. [Medline].
• Georgeson KE, Cohen RD, Hebra A, et al. Primary laparoscopic-assisted endorectal colon pull-through for Hirschsprung''s disease: a new gold standard. Ann Surg. May 1999;229(5):678-82; discussion 682-3. [Medline].
• IBD Working Group. Working Group of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). Inflammatory Bowel Disease in Children and Adolescents: Recommendations for Diagnosis-The Porto Criteria. J Pediatr Gastroenterol Nutr. 2005;41:1-7.
• Lang KA, Peppercorn MA. Promising new agents for the treatment of inflammatory bowel disorders. Drugs R D. Mar 1999;1(3):237-44. [Medline].
• Langer JC. Crohn disease. In: Surgery of Infants and Children. Philadelphia, Pa:. Lippincott-Raven;1997:1253.
• Langer JC, Seifert M, Minkes RK. One-stage Soave pull-through for Hirschsprung''s disease: a comparison of the transanal and open approaches. J Pediatr Surg. Jun 2000;35(6):820-2. [Medline].
• Lemberg DA, Clarkson CM, Bohane TD, Day AS. Role of esophagogastroduodenoscopy in the initial assessment of children with inflammatory bowel disease. J Gastroenterol Hepatol. Nov 2005;20(11):1696-700. [Medline].
• Lindberg E, Jarnerot G, Huitfeldt B. Smoking in Crohn''s disease: effect on localisation and clinical course. Gut. Jun 1992;33(6):779-82. [Medline].
• Liu CD, Rolandelli R, Ashley SW, et al. Laparoscopic surgery for inflammatory bowel disease. Am Surg. Dec 1995;61(12):1054-6. [Medline].
• Lowney JK, Dietz DW, Birnbaum EH, et al. Is there any difference in recurrence rates in laparoscopic ileocolic resection for Crohn's disease compared with conventional surgery? A long-term, follow-up study. Dis Colon Rectum. Jan 2006;49(1):58-63. [Medline].
• Markowitz J, Markowitz JE, Bousvaros A, et al. Workshop report: prevention of postoperative recurrence in Crohn's disease. J Pediatr Gastroenterol Nutr. Aug 2005;41(2):145-51. [Medline].
• McClane SJ, Rombeau JL. Anorectal Crohn''s disease. Surg Clin North Am. Feb 2001;81(1):169-83, ix. [Medline].
• Paerregaard A, Uldall Urne F. Anthropometry at the time of diagnosis in Danish children with inflammatory bowel disease. Acta Paediatr. Nov 2005;94(11):1682-3. [Medline].
• Pilleul F, Godefroy C, Yzebe-Beziat D, et al. Magnetic resonance imaging in Crohn's disease. Gastroenterol Clin Biol. Aug-Sep 2005;29(8-9):803-8. [Medline].
• Present DH, Korelitz BI, Wisch N, et al. Treatment of Crohn''s disease with 6-mercaptopurine. A long-term, randomized, double-blind study. N Engl J Med. May 1 1980;302(18):981-7. [Medline].
• Present DH, Rutgeerts P, Targan S, et al. Infliximab for the treatment of fistulas in patients with Crohn''s disease. N Engl J Med. May 6 1999;340(18):1398-405. [Medline].
• Reif S, Lavy A, Keter D, et al. Appendectomy is more frequent but not a risk factor in Crohn''s disease while being protective in ulcerative colitis: a comparison of surgical procedures in inflammatory bowel disease. Am J Gastroenterol. Mar 2001;96(3):829-32. [Medline].
• Rutgeerts P, Hiele M, Geboes K, et al. Controlled trial of metronidazole treatment for prevention of Crohn''s recurrence after ileal resection. Gastroenterology. Jun 1995;108(6):1617-21. [Medline].
• Sandborn WJ, Feagan BG, Hanauer SB, et al. An engineered human antibody to TNF (CDP571) for active Crohn's disease: A randomized double-blind placebo-controlled trial. Gastroenterology. 2001;120:1330-1338. [Medline].
• Sardinha TC, Wexner SD. Laparoscopy for inflammatory bowel disease: pros and cons. World J Surg. 1998;22:370-374. [Medline].
• Solem CA, Loftus EV, Tremaine WJ, et al. Correlation of C-reactive protein with clinical, endoscopic, histologic, and radiographic activity in inflammatory bowel disease. Inflamm Bowel Dis. Aug 2005;11(8):707-12. [Medline].
• Song HK, Buzby GP. Nutritional support for Crohn's disease. Surg Clin North Am. 2001;81:103-115. [Medline].
• Stronkhorst A, Radema S, Yong SL, et al. CD4 antibody treatment in patients with active Crohn''s disease: a phase 1 dose finding study. Gut. Mar 1997;40(3):320-7. [Medline].
• Tromm A, May D, Almus E, et al. Cutaneous manifestations in inflammatory bowel disease. Z Gastroenterol. Feb 2001;39(2):137-44. [Medline].
• Van Heel DA, McGovern DP, Jewell DP. Crohn''s disease: genetic susceptibility, bacteria, and innate immunity. Lancet. Jun 16 2001;357(9272):1902-4. [Medline].
• Vasiliauskas EA, Kam LY, Abreu-Martin MT, et al. An open-label pilot study of low-dose thalidomide in chronically active, steroid-dependent Crohn''s disease. Gastroenterology. Dec 1999;117(6):1278-87. [Medline].

Article Last Updated: Jul 6, 2006