Medical Management

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55 Colonic Conditions: Toxic Colitis

Fig. 55.2 CT ndings of pancolitis

the sensitivity and specicity of CT scan in diagnosing toxic colitis is low (52–85% and 48–92%), and approximately 40% of patients with toxic colitis will have normal CT scans, imaging can be useful in identifying the affected portions of colon, as well noting non-specic signs of inammation. Findings of severe colitis may include colonic wall thickening, ascites, mesenteric fat stranding, and colonic wall enhancement. Pathognomonic CT features of toxic megacolon include air-lled colonic distension >6 cm, an abnormal haustral pattern and wall thickening. The presence of mesenteric venous gas, pneumatosis intestinalis, or pneumoperitoneum is a sign of severe disease.

Abdominal radiographs, while less diagnostic, are useful, rapid adjuncts to diagnosis. An X-ray may show colonic distension, wallthickening, and air-uid levels.

D. Endoscopy

Endoscopy may be a useful adjunct in the diagnosis of toxic colitis. In infectious colitis, colonoscopy may show a pseudo- membrane. Pseudomembranous colitis is most commonly seen in C. difcile infection, however CMV is also a lesser-known cause. Cytomegalovirus (CMV), in the last ten years, has been increasingly recognized as a rare but morbid condition that may co-exist

425

with CDI, especially in immune-compromised or elderly patients. CMV is most accurately diagnosed with endoscopic biopsy and should be treated if positive.

Classic endoscopic ndings for UC include continuous friability, bowel wall edema, conuent erythema, and loss of vascular markings. Advanced stages may demonstrate ulceration, purulence and pseudo- polyp formation. Classic ndings on endoscopy for Crohn’s disease include ‘skip lesions’ and a ‘cobblestone’ appearance, as well as patchy erythema and aphthous ulceration. Advanced disease may show conuent ulcers, stricturing and mucosal bridging.

In the setting of severe colitis, fulminant colitis or toxic megacolon, endoscopy is contraindicated due to the high risk of perforation.

Medical Management

The goals of medical management of toxic colitis, regardless of etiology, should be aimed at stabilizing the patient, correcting uid and electrolyte disturbances, and treating the underlying disease process. Initial resuscitation should include aggressive uid replacement, transfusion if necessary, electrolyte repletion, and broad spectrum disease-specic antibiotic coverage. Medications that affect colonic motility should be discontinued. The patient should be admitted to an intensive care unit or a monitored setting, with Foley catheter insertion, strict I&Os, bowel rest and as needed nasogastric tube decompression.

E. PO Vancomycin and IV Flagyl for CDI

Antibiotic therapy for severe CDI is based on oral vancomycin 125–500mg four times daily and intravenous metronidazole 500 mg three times daily. The clinical success rate is 66.3% for metronidazole vs.

78.5% for vancomycin for severe CDI. Vancomycin enemas have also been used as an adjunct to primary therapy with success rates up to 70%.

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C. Fong and B. Abbadessa

F. IV Antibiotics for IBD

Antibiotic coverage should include broadspectrum coverage for colonic bacterial supra-infection or translocation.

G. Intravenous Steroids in IBD

In patients with IBD and toxic colitis, highdose intravenous steroids have been shown to be useful in avoiding colectomy in the short term in up to 25% of patients. Steroids should only be used as initial management and is not indicated in unstable patients or patients with free perforation or bowel ischemia or progressive colonic dilation. Sample regimens include hydrocortisone 100mg every 6h, methylprednisolone 16–20mg every 8h, or prednisolone 20mg every 8h.

H. IV Cyclosporine/Biologic Agents in IBD

In patients who do not show clinical improvement within 3–5days after initiation of steroid therapy, cyclosporine may be used as a rescue therapy in doses of 4mg/kg/day intravenously while maintaining high- dose intravenous steroids. This combination has a 67% response rate in the literature.

Marion etal. found that with the addition of 6-MP, 78% of cyclosporine responders avoided colectomy whereas only 36% of patients who did not receive 6-MP avoided surgery. Marion recommends the addition of 6-MP to all cyclosporine responders. Side effects of cyclosporine include renal toxicity, seizures, hypertension and opportunistic infections.

Biologics can also be considered as rescue therapy in patients who have failed treatment with intravenous steroids. In the literature, avoidance of colectomy can range from 25% to 90% of patients.

Risk Assessment

Mild to severe ulcerative colitis and Crohn’s colitis can be dened by the Truelove and Witts score (see Table 55.1), which incorporates vital signs, clinical and laboratory data. Utilizing the same parameters, fulminant colitis has been described

Table 55.1 Truelove and Witts score for inammatory bowel disease severity

Mild Moderate Severe Bowel movements (no. per day)

Blood in stools No

Pyrexia (temperature greater than

37.8°C) Pulse rate greater than 90bpm Anemia (<10g/100mL) Erythrocyte sedimentation rate (mm/h)

Fewer

than 4

than

small

amounts

of blood

No No Ye s

30 or

below

4–6 Six or more

Between mild and severe

30 or below

plus at least one of the features of systemic upset Visible blood

Above 30

by Jones et al. as fever, tachycardia, elevated ESR, >10 bloody bowel movements daily, continuous bleeding requiring blood transfusion, abdominal tenderness and distension as well as imaging evidence of colonic dilation. I. Toxic/Fulminant/Refractory Colitis

Regardless of the etiology, early surgical consultation is essential for patients with toxic colitis. Absolute indications for surgery include free perforation, massive hemorrhage (requiring greater than 6 units packed red blood cells), increasing toxicity (fever, leukocytosis, hypotension, tachycardia), and worsening colonic dilation. While older epithets advised conservative management for up to 1week in the absence of disease progression, failure to improve after 48–72h of medical management is a relative indication for surgery. Lower mortality rates have been associated with early surgery—4% mortality in non-perforated toxic colitis compared to 20% mortality in perforated toxic colitis.

55 Colonic Conditions: Toxic Colitis

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Surgical Management

There are many different operative approaches for toxic colitis. Early on, total procto-colectomy was the procedure of choice, but this has fallen out of favor because of the increased morbidity and mortality of operating in the pelvis, including increased risk of blood loss, sepsis, nerve damage, and small bowel obstruction. Three other approaches are described here, with the rationale and evidence for each.

J. Segmental Colectomy

There is no evidence in the literature to support a segmental colectomy in toxic megacolon or pancolitis. The pathophysiology of the disease does not support segmental resection, since toxic colitis can severely affect the entire colon and mucosal inammation may not be apparent on visual inspection of the serosa. In the rare setting of perforated segmental Crohn’s toxic colitis, a segmental colonic resection with fecal diversion has been performed for colon-sparing purposes. There has not been long-term follow-up regarding need for further resection or recurrence in these patients.

K. DLI+ICL

Historically, the Turnbull-Blowhole colostomy was described in 1971 to temporize patients with toxic megacolon due to IBD. This was a skin level colostomy and loop ileostomy used for colonic decompression and diversion. A more recent case series out of the University of Pittsburgh, published in 2011, built upon this technique and looked specically at C. difcile infection.

The Pittsburgh study treated 42 patients over a two-year period from 2009 to 2011 and found that diverting loop ileostomy and intraoperative colonic lavage (DLI +ICL) was a safe and colon-sparing alternative to the gold standard of subtotal colectomy with end ileostomy (SC+I). In their study, patients who came in with severe, fulminant CDI were taken to the operating room where a diverting loop ileostomy was created, and the colon

was lavaged intra- operatively with warmed polyethylene glycol solution (8 L) via the defunctionalized limb of the ileostomy. Postoperatively, patients were given antegrade vancomycin ushes (500mg q8h) for 10days while being treated with intravenous metronidazole. Eighty-three percent of the patients were treated laparoscopically.

The patients treated with DLI+ICL were matched to historic controls treated with subtotal colectomy and end ileostomy and were found to have a statistically signicant shorter time to normalization of leukocytosis (5.9 days), shorter time to return of bowel function (2.6days), a higher chance of ileostomy reversal (20% vs. 79%), and overall decreased mortality (19% vs. 50%). Only 3 out of the 35 patients (8%) who underwent laparoscopic DLI+ICL proceeded to require colectomy, either for abdominal compartment syndrome or recurrent vasopressor requirement. The colon was preserved in 39 out of 42 patients (93%).

Two small case series have attempted to validate the Pittsburgh results but this has not been replicated. In one study from Johnstown, PA, where two surgeons performed open DLI+ICL, three out of four patients showed clinical improvement post- operatively, and one patient expired post- operatively. The general consensus is that more prospective, randomized studies need to be done.

L. Total Abdominal/Subtotal Colectomy + End

Ileostomy

Subtotal colectomy with end ileostomy is the gold standard in the surgical treatment of toxic colitis. It was rst described by Crile in 1951, as the treatment for a case of acute toxic ulcerative colitis.

In severely ill patients with distended bowel, an open approach tends to be safest and most efcacious. The incision should be of adequate length to facilitate easy access to and mobilization of the colon in a lateral-to-medial fashion, with care taken to avoid perforation and intra-abdominal contamination, as the bowel will likely be friable and edematous.

428

C. Fong and B. Abbadessa

The mesentery and its vessels are divided close to the bowel wall. The small bowel is divided immediately proximal to the ileocecal valve to preserve the maximum length of small intestine for potential future reconstructive options. The colon is divided at the recto-sigmoid or distal sigmoid depending on the condition of the bowel. To prevent stump blowout, some surgeons reinforce the rectal stump staple line by over-sewing it and others prefer a longer Hartmann pouch brought up to the skin. In the latter technique, the sigmoid colon is exteriorized at the inferior portion of the midline wound and sutured to the fascial edges while the intact staple line remains above the level of the fascia and in the subcutaneous tissue. In one 2011 study from the Cleveland Clinic, the postoperative outcomes were found to be comparable whether the rectal stump was intraperitoneal or subcutaneous. Subcutaneous placement of the rectal stump was associated with a higher wound infection rate (13% vs. 5%), but this is considered to be less morbid than a rectal stump leak leading to pelvic sepsis. Transrectal drainage of the subcutaneous or rectal stump is also a decompressive option. The end ileostomy is then delivered through the rectus muscle and matured to 2 cm in a Brooke-type fashion. Timing of reversal of the stoma is based on patient factors and the underlying disease; generally the time frame is 3–6months.

Reconstructive options for UC include completion proctectomy with ileal pouch anal anastomosis (IPAA). In CDI, an ileorectal anastomosis can be performed. In Crohn’s disease with active anal or rectal disease, reconstruction is not recommended; in Crohn’s patients without active anal or rectal disease, a ileorectal anastomosis can be considered.

Crohn’s Colitis

MeaganM.Costedio andLeonardoC.Duraes

Refer toAlgorithms inFigs. 56.1 and56.2

A. Crohn’s disease (CD) is an inammatory dis-

order of unknown etiology that is thought to be related to genetic and environmental factors. It is estimated that 780,000 Americans currently have CD. The incidence of new cases of CD diagnosed each year is approximately 10.7 per 100,000 people. CD can occur at any age; however, people are most frequently diagnosed between 15 and 35years old. It is predominantly observed in developed countries. CD may involve any portion of GI system. Sixty percent of CD patients have colonic involvement. Half of those have disease in the colon only, half of whom have synchronous involvement of the small intestine.

B. CD symptoms are heterogeneous. Chronic

diarrhea is the most common symptom, followed by abdominal pain, weight loss, and blood and mucus in the stool which is seen in

M. M. Costedio (*) Department of Colorectal Surgery, Ahuja Medical Center of University Hospitals, Beachwood, OH, USA e-mail: meagan.costedio@uhhospitals.org

L. C. Duraes Ravitch Colorectal Surgery Division, Johns Hopkins Medical Institute, Baltimore, MD, USA

up to half of patients. Extra-intestinal manifestations are most common when CD affects the colon. Musculoskeletal system abnormalities encompassing peripheral and axial joints are the most common extra-intestinal manifestations, however dermatologic, oral, hepatopancreatobiliary, ocular, pulmonary or renal systems can also be involved. Perianal stulas are present in 10% of patients at the time of diagnosis, and can be the presenting symptom. Many patients have developed other medical complications of disease including malnutrition, adrenal insufciency and anemia.

C. CD can present with a variety of complex

phenotypes. Therefore, the diagnosis depends on a combination of clinical evaluation, endoscopic appearance, histological, radiological, surgical ndings, and biochemical investigation. The differential diagnosis of CD colitis includes ulcerative colitis (UC), indeterminate colitis, appendicitis, irritable bowel syndrome, microscopic colitis, infectious colitis, ischemic colitis, idiopathic colitis and cancer. When the disease is restricted to the colon, it may be difcult to differentiate from UC.Ten to twenty percent of cases of colitis cannot be classied and they are labeled indeterminate colitis.

D. Colonoscopy with multiple biopsies is the

rst line procedure for diagnosing colitis. Endoscopic features pathognomonic for CD are discontinuous involvement, anal lesions

https://doi.org/10.1007/978-3-319-65942-8_56

431

432

M. M. Costedio and L. C. Duraes

Fig. 56.1 Algorithm for management of Crohn’s colitis

and cobblestoning. Ileoscopy with biopsy increases the diagnostic yield of CD. Histologically, the nding of noncryptolytic granulomas, focal or patchy lamina propria chronic inammation, focal or anatomically discontinuous crypt distortion, and ileal involvement solidify CD diagnosis. MR or CT enterography have high accuracy for the detection of small bowel involvement of CD, including extramural complications such as stulae or abscesses. Abdominal X ray is used to evaluate for colonic distention. CT scans are helpful in the diagnosis of abscesses and or stulae. Serological biomarkers, including pANCA, ASCA, antiCBir1, anti- I2 and anti-OMPC, may be used to help with differential diagnosis among more common bowel diseases, especially in pediatric population. Elevated ASCA has 50–70% of sensitivity, and 80–85% of specicity for CD. On the other hand, elevated pANCA has a prevalence of only 6–20% in CD, but 65–70% of sensitivity and 80–85% of specicity for UC.Fecal calprotectin has

been shown to reect the severity of mucosal inammation in inammatory bowel diseases (IBD), and was shown to predict the relapse of CD.Anal examination is essential to diagnosis of anal CD.The most common anal presentations of CD are perianal abscess, anal stula, atypical anal ssure and sentinel tags. A minority of patients present with high/complex anal stulae, or recto-vaginal stulae.

E. CD has been classied by disease phenotype

(Montreal classication), by disease activity (Crohn’s Disease Activity Index—CDAI), and response to therapy (steroid-resistant or steroid-dependent). The Montreal classication categorizes CD according to patient age (16 years and younger—A1, 17–40 years— A2, over 40 years—A3), disease location (terminal ileum—L1, colon—L2, ileocolon—L3, upper GI location—L4), disease behavior (non-stricturing, non-penetrating— B1, stricturing—B2, penetrating—B3). CD phenotype may be used to elect appropriate surgical treatment. Sustained disabling symp-

56 Crohn’s Colitis

433

Fig. 56.2 Algorithm for surgical treatment of Crohn’s colitis. TAC/IRA total abdominal colectomy with ileo- rectal anastomosis, TPC/IPAA restorative total procto- colectomy with ileal pouch-anal anastomosis, TPC/EI

toms, impaired quality of life, abscesses, stulae, obstruction, inability to wean from steroids and need for surgery are factors used for clinically dening CD severity.

F. CD is associated with several complications,

such as perforation, abscesses, stulas, strictures, obstruction, malnutrition, hemorrhage, dysplasia, cancer, and toxic colitis. Patients with free perforation or toxic megacolon need emergent surgical treatment. Due to improved medical therapies, surgical management is more commonly used to manage complications. Patients with enteric stulae with symptoms require a resection. Intraabdominal abscesses can be treated with IV antibiotics and CT scan guided drainage. If the abscess responds, surgery can often be delayed. Patients with long-standing CD have

total proctocolectomy with end ileostomy, TPC/K pouch total proctocolectomy with continent ileostomy (K pouch), EC end colostomy. (Asterisk) Very rarely in highly selected well-informed patients

high risk of dysplasia and cancer. Patients with carcinoma, dysplasia-associated lesion or mass (DALM), high-grade dysplasia, or multifocal, low-grade dysplasia of the colon or rectum should undergo oncologic total proctocolectomy.

G. Medical treatment should take into consider-

ation activity, site and behavior of CD. The medication choice is also inuenced by previous response to treatment, potential sideeffects, complications, and extra-intestinal manifestations. Colonic CD activity and severity is easier to assess by colonoscopy than other areas. For colonic CD, systemic corticosteroids remain the rst-line therapy for acute exacerbations. For distal disease, topical therapy is an option such as mesalamine or steroid enemas. The use of

434

M. M. Costedio and L. C. Duraes

sulfasalazine, metronidazole, or dietary changes are useful in mildly active disease. Once the acute are is managed, immunomodulators are an option for patients with moderate to severe active disease. Recently, biologic therapies are being used in the early phase of the disease. Traditionally, anti-TNF agents have been indicated for patients that have persistent symptoms and unable to wean from steroids. However, efforts are being made to identify patients with aggressive disease, such as penetrating or anal disease, who may benet from early introduction of biologics, and change the pattern of future disease.

H. Both diagnostic and therapeutic endoscopy

are important tools in the management of CD.Endoscopic dilation and biopsy of stenoses in CD is the preferred technique for the management of accessible short segment strictures. Dilation carries a risk of perforation, and should be performed in institutions with surgical back-up. Surgery should be reserved for longer strictures, failed endoscopic treatment, or if there is concern for cancer. Colonoscopy is used to monitor disease response to therapy as well as monitor for dysplasia or malignancy in patients with long-standing CD.According to AGA guidelines, patients with Crohn’s colitis who have disease involving at least one third of the length of the colon, should undergo a screening colonoscopy a maximum of 8years after onset of symptoms, with four biopsies every 10cm throughout the entire colon. After two negative examinations (no dysplasia or cancer), further surveillance examinations should be performed every 1–3years.

I. Surgical treatment has evolved due to recent

developments in medical therapy. Surgery is most often performed in cases of failure of medical treatment or disease complications. Therefore, patients referred to surgery have complicated disease, and or a higher perioperative risk due to medical comorbidities. Unlike small bowel CD, there is less of need to preserve the large bowel during surgery. Surgical strategy is mainly based on location and duration of disease, urgency of

intervention, presence of complications, and the general condition of the patient. Patients with abscesses, internal stulas, or stenosis are considered for surgery at an earlier stage of the disease. Nutritional, medical, social and psychological factors need to be considered in the surgical treatment plan. Smoking is a major factor for recurrence, and patients should be strongly encouraged to stop smoking before surgery.

J. When a patient with colonic CD requires

emergent or urgent surgery, subtotal or total colectomy with end ileostomy with Hartmann’s closure of the distal bowel or creation of mucous stula is the safest procedure, particularly in cases of failure of medical therapy when the patients are physiologically ill. In patients not taking immunomodulating agents who have acute perforation and are otherwise well, segmental resection with primary anastomosis with or without diverting loop ileostomy is an option.

K. For localized colonic disease involving less

than a third of the colon, segmental colectomy is preferable. This approach has lower risk of permanent stoma, but higher risk of recurrence compared to total proctocolectomy. Multi-segment colonic disease with rectal sparing can be treated with subtotal colectomy with ileo-rectal anastomosis or multiple segmental resections. The minimally invasive approach has proven short term recovery benets as well as the long term benet of decreased adhesions for future surgeries. That being said Crohn’s disease can be challenging laparoscopically and requires advanced technical skill and surgeon comfort. Stricturoplasty is not recommended due to the increased risk of cancer in a colonic stricture. In patients with pancolitis where the rectum is spared, total abdominal colectomy with ileo-rectal anastomosis is the preferred surgical option.

L. In patients with pancolitis and small bowel

and anal sparing, restorative proctocolectomy with ileo pouch-anal anastomosis (IPAA) or Koch pouch may be an option to avoid permanent ileostomy. However, IPAA

56 Crohn’s Colitis

435

in Crohn’s carries higher complication and pouch failure rates compared to UC or indeterminate colitis. This option may be offered on very rare occasions to well informed patients. Its widespread use is not encouraged. Total proctocolectomy with end ileostomy is the only surgical option for patients with pancolitis and anal or small bowel involvement.

Medical Management

Risk Assessment

Surgical Management

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Crohn’s Colitis

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