Clinical Presentation A 28-year-old woman with a 6-year history of colitis with rectal sparing. Her symptoms have increased recently and are manifested by abdominal pain and bloody diarrhea. She is chronically anemic but has not required any blood transfusions. The colon is palpable on abdominal exam, and she is tender in the left lower quadrant over the sigmoid colon.

Diagnostic Studies Colonoscopy showed mild rectal inammation with severe colitis throughout the remaining colon with deep ulcerations and cobblestoning of the regenerating mucosa (see Fig.6.5b).

Surgical Treatment This patient underwent a total colectomy with ileorectal anas-

tomosis. The small bowel was normal (see Fig.6.5a).

Pathology Severe granulomatous colitis with extensive ulceration, pseudopolypo-

sis, and crypt abscesses.

Follow-Up She recovered well following surgery. Her anemia improved rapidly

with oral iron supplements, and she is doing well several years later.

Comment This is a common presentation for patients with moderately severe

granulomatous colitis. The rectum is often spared, and therefore, a subtotal colectomy with ileorectal anastomosis is feasible. These patients require continued medical treatment following surgery in order to prevent a recurrence in the neoterminal ileum and to avoid exacerbation in the residual rectum. Many of these patients eventually require further surgery and some may need resection of the rectum with a Brooke ileostomy. Most patients in this age group would rather have an anastomosis with a higher possibility of requiring further surgery than a permanent ileostomy and a lower recurrence potential (Fig.6.5).

granulomatous

ous

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Diffuse

colitis

Ileocecal valve

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Sigmoid colon

Fig. 6.5 Granulomatous colitis with rectal sparing

Granulomat colitis

6 Granulomatous Colitis

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6.6 Granulomatous Proctitis withStricture

Clinical Presentation A 37-year-old man with Crohn’s disease for 20years. He has severe granulomatous colitis with a perianal stula and a stricture of the distal rectum, which precludes colonoscopic surveillance.

Diagnostic Studies Anorectal exam showed a healed stulotomy scar. The distal rectum could be examined with difculty using the smallest diameter pediatric sigmoidoscope and showed severe inammation. Barium enema showed an 8cm stricture of the distal rectum. Intraoperative endoscopy conrmed the presence of severe rectal disease and showed that the rest of the colon was unremarkable (see Fig.6.6c).

Surgical Findings Normal small bowel and colon with severe anorectal disease. He underwent an abdominoperineal resection of the rectum with a sigmoid colostomy (see Fig.6.6a, b).

Pathology Crohn’s proctocolitis with transmural chronic inammation and stric-

ture. Multiple nonnecrotizing epithelioid cell granulomas are present.

Follow-Up He did well following surgery. The perineal wound healed well. He is

currently asymptomatic and irrigates the colostomy every other day.

Comment This patient demonstrates the severity of rectal disease in granuloma-

tous colitis. The perianal disease manifested by a perianal stula was relatively mild and responded to surgical treatment. The severity of the rectal inammation, however, produced a strictured ulcerated rectum, which eventually required surgical resection. Difculty with surveillance colonoscopy as well as severity of symptoms unresponsive to medical treatment were the main indications for surgery. He has adapted well to the colostomy (Fig.6.6).

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Rectum

vere proctitis

Anal canal

Granulomatous proctitis with stricture

Fig. 6.6

Granulomatous proctitis

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Fig. 6.6 (continued)

Severe anorectal

stricture

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Extensive Granulomatous Colitis

TomasM.Heimann andRobertJ.Kurtz

Extensive granulomatous colitis causes symptoms that mimic those seen in ulcerative colitis.

Granulomatous colitis differs, however, from ulcerative colitis in that it is more likely to form strictures and stulas in adjacent organs that are common. In addition, the presence of perianal disease makes granulomatous colitis more difcult to treat. Patients with impassable strictures, which prevent surveillance of the colon, often require colectomy. In addition to intractability, colorectal cancer risk in granulomatous colitis seems to be increased and is probably similar to that seen in ulcerative colitis. The surgical treatment of granulomatous colitis, if the rectum is spared, is subtotal colectomy with ileorectal anastomosis.

When there is severe rectal or perianal disease, proctocolectomy may be necessary. Except in very unusual circumstances, patients with granulomatous colitis and colorectal cancer should undergo proctocolectomy and ileostomy.

7.1 Crohn’s Presenting asUlcerative Colitis

Clinical Presentation A 73-year-old man with the diagnosis of ulcerative colitis present for 30years. Recent increase in symptoms with weight loss, diarrhea, and bleeding requiring hospitalization and blood transfusion. There was no improvement in his symptoms with a course of high-dose steroids.

Diagnostic Studies Severe colitis with multiple pseudopolyps seen on recent colonoscopy (see Fig. 7.1d).

T. M. Heimann (*) · R. J. Kurtz Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA e-mail: Tomas.Heimann@mountsinai.org; Robert.Kurtz@mountsinai.org

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 T. M. Heimann (ed.), Atlas of Surgical Treatment of Inammatory Bowel Disease, https://doi.org/10.1007/978-3-031-62431-5_7

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Surgical Treatment A proctocolectomy and Brooke ileostomy were performed.

The colon showed severe colitis without the typical stigmata of Crohn’s disease, and the small bowel was normal (see Fig. 7.1a, b, c).

Pathology Severely active Crohn’s proctocolitis with patchy ulcerations, inam-

matory polyposis, and mucosal chronic inammation. Lymphoid aggregates are present in the deep submucosa and subserosa with epithelioid cell granulomas seen in several sections.

Follow-Up The patient had an uneventful postoperative recovery. He developed a

stricture of the ileostomy, which required a supercial revision 2months later. He is doing well and returned to his normal weight. The perineal wound required several months to heal completely.

Comment This patient had recent exacerbation of his colitis manifested by severe

diarrhea, weight loss, and bleeding. The endoscopic appearance of the colon was consistent with severe ulcerative colitis, and the small bowel was normal. The presence of epithelioid granulomas, however, was pathognomonic of granulomatous colitis. If this patient had been younger, he would have had an ileoanal pull-through procedure, since colonoscopic biopsies prior to surgery did not reveal the presence of granulomas and the appearance of the colon at the time of surgery was not typical of Crohn’s disease. Although there was no perianal disease, the chance of failure after the ileoanal pull-through operation is signicantly higher in patients with Crohn’s colitis (Fig.7.1).