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General Surgery
Perspective on Inflammatory Bowel Disease (A)
Built from Maingot's Abdominal Operations
What’s inside
4 sections · 45 slides
Overview
- Scope of this perspective
- Inflamed, thickened segment of small bowel
- Three areas of controversy
Is Crohn's disease a lymphoobliterative disease?
Blocked lymph drainage as a possible first step
- Accepted view of how Crohn's disease starts
- Mucosal immune response in normal and Crohn's bowel
- Histopathologic changes in Crohn's lymphatics
- Granuloma in colorectal mucosa
- Evidence from animal models
- Proposed lymphoobliterative sequence
- Effects of early lymphatic obstruction
- Fat wrapping and mesenteric thickening
- Surgical implication of the lymphatic hypothesis
Aggressive early medical therapy versus surgical therapy
Top-down drugs at diagnosis, or an early operation?
- Two strategies for starting treatment
- Top-down compared with bottom-up
- Trial evidence for early aggressive medical therapy
- Infliximab with azathioprine in immunomodulator-naive patients
- 62% vs 42%
- Immunologic rationale for top-down therapy
- Scheduled versus episodic infliximab
- Reassessment for medical failure
- Operating after recent anti-TNF exposure
- Case for early surgery in ileocolic disease
- Patchy bowel involvement with normal segments between
- Preferences of clinicians and patients
- Randomized trial of early terminal ileal resection
- An evolving treatment strategy
The role of prophylactic medical therapy postresection
What, if anything, to give once the bowel has been resected
- What surgery achieves in Crohn's disease
- Recurrence after resection
- Opened bowel segment with an ulcerated, cobbled lining
- Options for prophylaxis after resection
- Probiotics after resection
- Lactobacillus bacteria under the electron microscope
- Nitroimidazole antibiotics after resection
- Mesalamine after resection
- 5-aminosalicylic acid molecule
- Azathioprine after resection
- Azathioprine molecule
- Choosing who receives prophylaxis
- Suggested prophylaxis strategy
- Future directions in understanding Crohn's disease
- Key points to carry away
- References
- References (continued)
- References (continued)
- Maingot's Abdominal Operations, 12th Edition