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Chapter 60
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Case on Recurrence of Crohn’s Disease
Adriaan A. van Bodegraven
Keywords Crohn’s disease • Recurrent Crohn disease • Intestinal obstruction •
Intestinal resection
First Patient
Diagnosis and Indication for Surgery
During military service in the midst of the 1980s, a 23-year-old male patient known
with Crohn’s disease presented with symptoms of stenosis of small bowel. Crohn’s
disease had been localized in the small bowel (Montreal classifi cation L1 + L4).
Patient was operated on; the disease was surgically removed “completely”—according to medical opinion holding for that era of time—at two instances, the fi rst in
1984 involving extended ileocecal resection and the second in 1987 involving partial jejunum resection. Documentation was scarce, but according to histology
reports, at least 1.5 m of small bowel was removed. From 1990 on, the patient had
experienced relapse of obstructive symptoms, due to recurrence of disease, notwithstanding maintenance therapy with varying dosages of corticosteroids (between 5
and 20 mg prednisolone o.d.) (Fig. 60.1 ). He presented at our third-line referral
hospital and was refereed by another gastroenterologist because of a recurrence of
multiple stenosis in remaining jejunum and ileum.
He was advised to adapt his diet to frequent, preferably liquid, small meals. This
was carefully monitored for recurrent follow-up of symptoms and laboratory studies
to assess infl ammatory parameters and drug-related toxicity. Intercurrent occlusion
A. A. van Bodegraven
Department of Gastroenterology , VU University Medical Center , Amsterdam , The Netherlands
e-mail: v.bodegraven@vumc.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_60,
© Springer International Publishing Switzerland 2014
315
316
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A.A. van Bodegraven
of central retinae vein of the right eye occurred (Fig. 60.2 ), an uncommon but well-
known extra-intestinal manifestation of IBD, decreasing the sight in that eye to less
than a 30 %. Later, in addition, cornea dysplasia of both eyes was diagnosed.
Fig. 60.1 Colonoscopy
showing Crohn’s disease,
being biopsied
Fig. 60.2 Cornea dysplasia of both eyes
60 Case on Recurrence of Crohn’s Disease
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317
Nevertheless, symptoms increased, and in the absence of infl ammation, surgical
therapy was again advised.
Operation
Laparotomy followed in 1996 to address the symptomatic and quiescent (cold) stenosis in order to perform bowel-sparing procedures, and fi ve stricturoplasties were
performed; whereas the most proximal stenosis over 10 cm length was treated by a
side-to-side anastomosis. After this operation, he maintained quite well his general
condition and was able to work adequately.
Postoperative Course
Nevertheless, recurrence of complaints and disease activity returned in 2002
(Fig. 60.3 ), prompting another laparotomy during which two other stricturoplasties
and resection of the neo-terminal ileum, 15 cm, were performed. Approximately
180 cm of small bowel remained. This procedure was complicated by a leakage, and
so relaparotomy was performed, and an ileostomy and colonic fi stula were created.
Fig. 60.3 MRI enteroclysis:
dilatation jejunum and
thickness intestinal wall
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Two relaparotomies were performed shortly after drain and rinse of the peritoneal
cavity. Late in 2003, intestinal continuity was performed without further
complications.
After the latest operations, patient persistently produced voluminous stools and
had a slow but progressive loss of weight. Treatment consisted nonetheless in hyperphagia based on a calculated and measured energy need and corrected for fecal
energy losses (indirect calorimetry and fecal bomb calorimetry). Finally, a percutaneous endoscopic gastrostomy was placed to warrant continuous dripping of predigested enteral feeding allowing for 24-h nutrition via a pump device.
Currently, his weight is stable. However, again stenotic symptoms do occur, and
again in the neo-terminal ileum, active Crohn’s disease has been diagnosed
(Fig. 60.4a ), notwithstanding treatment with at fi rst subcutaneous methotrexate,
later in combination with infl iximab, and now monotherapy with adalimumab
40 mg o.w. Patient has recently been operated, fi nding a fi brotic mass around the
distal anastomosis (Fig. 60.4b ). Twenty-centimeter resection has been performed
with side-to-side anastomosis. Seventy centimeters of small bowel and from the
transverse colon are remaining.
A.A. van Bodegraven
Discussion
“Complete” resection of Crohn’s disease has been abandoned since long, as it does
not preclude recurrence of disease in the remaining bowel. Therefore, current surgical approach in Crohn’s disease comprises minimal resection and preferably so
minimally invasive, the latter referring to laparoscopic techniques being preferable
over open approach [ 1 ]. In general, a patient with Crohn’s disease has a chance of
70–80 % to be operated once, whereas 50 % may encounter a second procedure.
Extensive resection of the (small) bowel must be avoided whenever possible.
Therefore, prior to surgery the disease should preferably be in a quiescent stage, and
infi ltration, abscesses, and other complicating factors should be treated by means of
antibiotics and enteral feeding or percutaneously by drains, whenever possible.
There is debate whether the total length of the small bowel is generally less in
patients with Crohn’s disease, even before surgery. This factor in itself might contribute to a higher chance of getting clinically signifi cant short bowel syndrome,
which is leading to nutritional and energetic defi ciencies. Anyhow, following each
surgical procedure for Crohn’s disease, remaining small bowel length has to be
carefully documented (with or without duodenum, Bauhin’s valve, and length of
remaining colon) to have an indication of the functional bowel and estimation for
60 Case on Recurrence of Crohn’s Disease
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Fig. 60.4 MRI enteroclysis:
small bowel dilatation,
recurrence Crohn’s disease
a
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b
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Fig. 60.5 MRI enteroclysis
showing stenosis neoterminal ileum
A.A. van Bodegraven
clinically signifi cant intestinal failure. This might prompt commencing with nutritional guidance at an early stage, including the adoption of medical therapy that
usually has lower bioavailability due to suboptimal intestinal absorption, sometimes
necessitating different administration routes (subcutaneously, intravenously).
Additionally, careful monitoring of postsurgical intestinal function by a dedicated
(nutritional) team is warranted [ 2 – 6 ].
Second Patient
Diagnosis and Indication for Surgery
A 19-year-old patient had in 1990 been diagnosed with Crohn’s disease of the terminal ileum. Stenosis of this segment, without infl ammatory signs in laboratory
studies or at radiography, was treated by open ileocecal resection in 1992. Recurrence
of stenotic disease necessitated reresection of the neo-terminal ileum in 1999, and
again in 2006 (Figs.
60.5 and 60.6 ). The latest operation included a right-sided
60 Case on Recurrence of Crohn’s Disease
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Fig. 60.6 MRI enteroclysis
showing restenosis of the
neo-terminal ileum
321
hemicolectomy due to a spontaneous enterocutaneous fi stula formation. Furthermore,
a perianal abscess had to be drained in 1998.
Besides Crohn’s disease, this patient was diagnosed with HLA-B27-negative
sacroiliitis, fi tting with an IBD-associated spondyloarthropathy, and osteopenia.
Supplementation of vitamin B12 was initiated after the fi rst surgical procedure.
All surgical procedures were uneventful. Following operation, symptoms disappeared for long period of time. At the time of recurrence with symptoms including usually a combination of infl ammatory signs, right under quadrant pain
especially following meals and general depression, medical treatment was reinitiated, whereas in the asymptomatic periods, adherence to medical treatment was
suboptimal. Although induction to remission of disease activity was repetitively
successful, remaining complaints obliged to reoperations, the last one in an
extended form to remove the described fi stula. Currently, the patient suffers from
active Crohn’s disease of the neo-terminal ileum with abdominal cramps following large meals, notwithstanding potent anti-TNF alpha therapy (adalimumab
40 mg o.w.).
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A.A. van Bodegraven
Discussion
Crohn’s disease is phenotypically characterized by age of diagnosis, localization of
disease, and disease behavior in the so-called Montreal classifi cation [ 7 ]. Initially,
this classifi cation intended to be helpful in prediction of disease course, but its accuracy is limited in this respect. Lifetime chance for operation, when diagnosed with
Crohn’s disease, is approximately 70–80 % with a 50 % chance of reoperation
within the next 10 years. Clinically, specifi cally stenotic type of disease behavior is
associated with recurrent surgery. Up till now, no medical therapy has clearly been
demonstrated to decrease relapse leading to surgical reintervention, in particular
when taking adverse response, as with metronidazol or imidazol derivatives, or
costs, as with anti-TNF alpha therapy, are taken into consideration. Anyhow, only a
relative small number of studies addressed this issue. Additionally, there is a high
diversity in phenotype of Crohn’s disease patients with a different “a priori” chance
of surgical relapse. In order to predict recurrence of disease, Rutgeerts et al. suggested to assess an endoscopic score of mucosal lesions of the neo-terminal ileum,
following ileocecal resection, being a biomarker of mucosal infl ammation, clinical
recurrence, and eventually surgical relapse, respectively [ 8 ]. This procedure might
be performed in the 6–12 months following fi rst operation. Currently fecal calprotectin bears potential as a biomarker of recurrence of mucosal damage after resection and, thus, might be considered as simple biomarker [ 9 ]. Nevertheless, up till
now, no clear-cut medical treatment strategy is known to avoid second or more
surgical interventions.
References
1. Maartense S, Dunker MS, Slors JF, et al. Laparoscopic assisted versus open ileocolic resection
for Crohn’s disease: a randomised trial. Ann Surg. 2006;243:143–9.
2. Ambe R, Campbell L, Cagir A. Comprehensive review of strictureplasty techniques in Crohn’s
disease: types, indications, comparisons, and safety. J Gastrointest Surg. 2012;16:209–17.
3. Lewis RT, Maron DJ. Effi cacy and complications of surgery for Crohn’s disease. Gastroenterol
Hepatol (NY). 2010;6:587–96.
4. Spinelli A, Sacchi M, Fiorino G, et al. Risk of postoperative recurrence and postoperative
management of Crohn’s disease. World J Gastroenterol. 2011;17:3213–9.
5. Thompson JS, Iyer KR, DiBaise JK, et al. Short bowel syndrome and Crohn’s disease. J
Gastrointest Surg. 2003;7:1069–72.
6. Donohoe CL, Reynolds JV. Short bowel syndrome. Surgeon. 2010;8:270–9.
7. Satsangi J, Silverberg MS, Vermeire S, Colombel JF. The Montreal classifi cation of
Infl ammatory bowel disease: controversies, consensus and implications. Gut. 2006;55:
749–53.
8. Daperno M, D’Haens G, Van Assche G, et al. Development and validation of a new, simplifi ed
endoscopic activity score for Crohn’s disease: the SES-CD. Gastrointest Endosc. 2004;60:
505–12.
9. D’Haens G, Ferrante M, Vermeire S, et al. Fecal calprotectin is a surrogate marker for endo-
scopic lesions in infl ammatory bowel disease. Infl amm Bowel Dis. 2012;18:2218–24.
Another patient presenting with a highly complicated, but generally considered,
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benign course of Crohn’s disease is currently 52-year-old man with a length of
1.85 m and with an initial bodyweight of approximately 90 kg. The patient’s initial
symptoms and diagnosis had already been encountered in 1988—he then was 29
years of age. His steroid-refractory ileocolonic disease led to partial colectomy of
the descending colon. Once he presented at our hospital, the active colonic disease
had recurred, even though postoperatively azathioprine had been prescribed to prevent postsurgical relapses. Moreover, Crohn’s disease was at that time complicated
by an enterovesical fi stula.
Operation Description
A low anterior resection, fi stulectomy, closure of the bladder, and creation of colostomy had then been performed.
A. A. van Bodegraven
Department of Gastroenterology , VU University Medical Center ,
Amsterdam , The Netherlands
e-mail: v.bodegraven@vumc.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_61,
© Springer International Publishing Switzerland 2014
323
324
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A.A. van Bodegraven
Postoperative Course
Two years later, the terminal ileum had become so stenosed that he was admitted
because of an ileus; consequently, an ileocecal resection was performed with a
side-to- side anastomosis. During the following years, the course of the disease
proved uneventful, with use of azathioprine and short courses of corticosteroids,
leading to a gradual increase of bodyweight up to 101 kg. In 2000, his complaints returned, involving colics as caused by a stenosis of the neo-terminal
ileum. Compassionate use of infl iximab—introduced at that time in the
Netherlands—failed to relieve his symptoms, necessitating another resection of
the stenosed neo-terminal ileum with end-to-end anastomosis, and approximately 20 cm of colon remaining. Due to adhesions, recovery was delayed by
postoperative ileus, which 3 weeks later necessitated a relaparotomy involving
adhesiolysis and resection of the distal part of the jejunum. The patient’s clinical
recovery during the next 2 years remained incomplete, due to his recurrent
abdominal pains and decreased appetite, as evidenced by a slow decrease of his
weight to 84 kg.
Two years afterward, once again small bowel disease recurred, primarily of the
stenotizing type, which induced symptomatology such as cramps and abdominal
pain, loss of weight, and ileus-like episodes. It was then decided to perform stricturoplasty; however, this was complicated by postoperative leakage through the laparotomy wound. This complication was treated by an open abdominal approach with
enteral nutrition, the frequent use of antibiotics, and by opiates. The combination
of the preoperative and relatively short bowel length, together with the presence of
at least three enterocutaneous fi stulas, induced a full-blown intestinal failure.
Enteral feeding was insuffi cient to maintain the patient’s bodyweight and additional parenteral feeding became required. Yet, due to chronic infl ammation
induced catabolism and feeding problems his weight continued to decrease to
64.5 kg. After approximately 1 year of supportive nutritional therapy, in combination with methotrexate monotherapy, and allergic reaction to infl iximab, we decided
to close the enterocutaneous fi stulas, one of them localized above the left anterior
spine. Although most infl ammation and scar tissue could be removed and intestinal
continuity was completed, once again a postoperative fi stula formed. Three months
later, it was closed by a new laparotomy. The remaining small bowel was considered to be 70–80 cm, with 30 cm colon and rectum. Then, fi nally, the intestinal
disease and Crohn’s manifestations went into remission, leaving the patient with a
short bowel syndrome. A period of hyperphagia with supplemental vitamin and
trace elements was introduced to adapt the remainder of the intestine. Over time,
TPN and supplements could be discontinued, and his bodyweight slowly increased.
Following this strategy, in 2006 his bodyweight had risen to 86 kg, and adalimumab
therapy was given to treat recurrence of infl ammatory luminal disease. Since then,
no further manifestations of Crohn’s disease have required other surgical procedures. Remarkably, the patient’s current weight is 108 kg, apparently brought about
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