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Surgery for Crohn’s Disease

Up to 3 million Americans have Crohn’s disease, a chronic condition that causes inflammation of the gastrointestinal tract.

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What is Crohn’s disease?

Crohn’s disease is an incurable inflammatory disorder that can affect any part of the gastrointestinal tract. The gastrointestinal tract is a system of body organs responsible for carrying and digesting food, absorbing nutrients, and getting rid of waste. Inflammation (red, swollen, and tender areas) always affects the innermost lining of the gastrointestinal tract, called the mucosa. However, the disease can affect the deeper layers of the gastrointestinal wall and even extend through the entire bowel wall. The exact cause of Crohn’s disease is unknown. Current research is exploring the possible connection of the disease to immune system problems and bacterial infections. 

What are typical symptoms of Crohn’s disease?

Crohn’s disease can present as abdominal disease, anorectal (anus and rectum) disease, or both. Patients with Crohn’s disease are at greater risk of developing a fistula. A fistula is a small tunnel that tracks from one portion of bowel to either another portion of bowel, another organ, or the skin. Symptoms vary widely among patients and often come and go over a long period of time. 

Possible symptoms include:

  • Abdominal cramping
  • Anal fissures 
  • Abdominal pain
  • Ongoing diarrhea
  • Chronic constipation
  • Fever
  • Extreme tiredness
  • Weight loss
  • Bleeding with bowel movements
  • Drainage from the skin around the anus
  • Abscesses (infections) around the anus that recur (come back)

How is Crohn’s disease diagnosed?

Crohn’s disease is typically diagnosed and treated by gastroenterologists (GI doctors), but your first encounter with a doctor regarding your issues may be with a colon and rectal surgeon. During the first visit, your colon and rectal surgeon will perform a thorough medical history and physical exam. To aid in diagnosis, they may also examine the inside of the bowel using a flexible instrument with a lighted camera. X-ray studies and laboratory tests such as stool samples and blood tests may also be done. This evaluation will provide information on the extent of disease and help guide treatment. 

How is Crohn’s disease treated?

Medications are always the first option unless emergency surgery is required. Several treatment approaches are used at the onset and for the long term to help patients control their disease. The most common initial therapy includes anti-inflammatory medications. Diet and lifestyle changes can also help. Medical treatment and monitoring of your Crohn’s disease is typically done by a gastroenterologist. 

Surgery may be needed when patients develop disease-related abdominal and anorectal complications. Emergency surgery may be performed when a patient has either a perforation (a hole in their bowel) or a blockage of the bowel. Both of these conditions can be life-threatening. Immediate surgery may also be required for an abscess near the anus.

Abdominal surgery: Surgery is typically performed when the patient’s symptoms are no longer being controlled with their medications. This usually means there is a section of bowel that is either too scarred or narrow to function properly. The surgery can be performed either through an open approach or a minimally invasive approach, such as laparoscopic surgery or robotic-assisted laparoscopic surgery. Your surgeon will decide on the safest approach based on your individual case.

The most common procedure is removal of the last portion of the small bowel and the first portion of the large bowel to relieve an abnormal, narrowed section. Following removal of this part of the bowel, the remaining bowel is reconnected if possible. The end of the bowel can also be brought out through a surgical opening in the skin of the abdominal wall. This procedure (called an ostomy) redirects waste (feces) from the bowels.

Anorectal surgery: This is most commonly done to open and drain anorectal abscesses. A seton (small drain) may be left in place for a period of time until the infection clears up. Surgery is also used to treat anorectal fistulas. In combination with this procedure, an ostomy may be created, but usually only in severe cases. 

Post-treatment Prognosis

It is important to follow up with your physicians so they can devise an ongoing management plan to control your symptoms. When you have Crohn’s disease, you must stay on medication throughout your entire life. Crohn’s that impacts the colon (large intestine) increases your risk of colon cancer. This risk goes up after 8 to 10 years of ongoing colon involvement. For those patients, it is key to undergo regular follow-up colonoscopies (examination of the colon using a flexible instrument with a lighted camera). 

How can I reduce my risk of recurrence?

Recurrence is most common in patients who stop taking their medications, so it is vital to follow your physician’s orders. Smoking negatively impacts every organ in the body and presents health risks for everyone, so quitting is advised. For patients with Crohn’s disease, smoking has been linked to higher recurrence rates, so quitting can reduce this risk. 

What is ulcerative colitis?

Ulcerative colitis (UC) is an inflammatory disease affecting the large bowel (colon and rectum). In UC, the inflammation is confined to the internal lining of the intestinal wall (mucosa). Medical management is typically the first option for treatment. UC can go into remission and recur (come and go). If surgery is needed for UC, it is usually curative. The exact cause of UC is unknown, but it is not contagious. Potential causes include immune system abnormalities and bacterial infection.

Is there anything that increases my risk of ulcerative colitis? 

Men and women are affected equally and people of all ages can develop UC. A family history of UC slightly increases the risk of the disease. 

What are the symptoms of ulcerative colitis?

Most patients develop symptoms in their 30s. A smaller number experience symptoms for the first time later in life (ages 60 to 70). The symptoms of UC are similar to another inflammatory bowel disease, Crohn’s disease. UC, however, only affects the colon and rectum. 

The most common symptoms of UC include:

  • Abdominal cramping
  • Pain
  • Diarrhea
  • Bleeding with bowel movements
  • Fever
  • Fatigue
  • Weight loss 

How is ulcerative colitis diagnosed?

Ulcerative colitis should be diagnosed by your doctor. Often, a colonoscopy is performed to diagnose UC. A colonoscopy looks at the inside of your colon and rectum to find ulcers and inflammation characteristic of UC. This evaluation helps determine the extent and severity of UC, rules out other diseases such as Crohn’s disease, and guides management. Additional testing may include blood tests, stool samples or imaging such as CT scans or X rays. 

How is ulcerative colitis treated?

Medical treatment is the first choice for most patients with ulcerative colitis and is typically prescribed and managed by gastroenterologists. The goal of medical therapy is to treat the inflammation and improve a patient’s quality of life by decreasing the diarrhea, bleeding, and pain. Long-term medications called immunosuppressants or anti-inflammatory medications are commonly used. Initially, the most common therapy is corticosteroids, but these should only be given briefly because of the side effects. Based on the extent of the disease, medications may be taken by mouth or as a rectal suppository. 

Surgery is considered for patients when medical management is no longer effective. Other reasons that a patient may require surgery include the development of cancer or pre-cancer in the setting of ulcerative colitis. Sometimes surgery needs to be performed when a complication of the disease occurs such as a perforated bowel (hole in the bowel), severe bleeding or serious infection (toxic colitis). 

UC involves only the colon and rectum and complete removal of both may be curative. Initially, this would require an ileostomy, or stoma. Some patients may be candidates for an ileal pouch which reconnects the small intestines to the anus. This procedure involves the removal of the entire colon and all of the rectum with the exception of the last section where the sphincter muscles (the muscles that control bowel movements) are located. The small bowel is then used to create a “new” rectum (the pouch). Because this pouch is often made in the shape of a “J”, it is often called a “J-pouch”. The patient will have a temporary ileostomy during the healing period; however, ultimately this will be removed and the patient will be able to pass stool through their anus again. 

Planned and emergency surgeries can be performed through traditional “open” procedures or minimally invasive (laparoscopic or robotic) approaches depending on the circumstances. The safest, most effective approach is determined on an individual basis. 

Because emergency surgery is done for potentially life threatening conditions, it may need to done as an open procedure. During emergency surgery, the large bowel (colon) is removed. The rectum and anus are left in place temporarily. The end of the small bowel (ileum) is brought out through the abdominal wall to the skin as a stoma/ileostomy where stool is allowed to empty into a bag attached to the skin. 

After recovery, a second procedure can be performed electively. During this surgery, the diseased rectum is removed. A new rectum (ileal pouch) is created using the small bowel. The new rectum is connected to the anal opening. A loop ileostomy is created to protect the area until it has healed. 

When healing is complete, a third procedure is done to close the ileostomy. This three-stage UC procedure ultimately results in patients being able to live without an ileostomy. 

In elective surgery, the first and second stages described above are combined. This is the two-stage surgery for UC, done through a minimally invasive or open procedure. Both the colon and rectum are removed. A new rectum or J-pouch is made from the small intestine and connected to the anal opening. A diverting loop ileostomy is often made to protect the area until it heals. After the patient recovers, a second procedure is performed to close the ileostomy and reconnect the small bowel. In select cases, some surgeons choose not to create a diverting ileostomy, which results in a one-stage procedure. 

Sometimes a J pouch is not possible for various reasons or a patient chooses not to have a J pouch, and, instead, the entire colon, rectum, and anus are removed, and a permanent ileostomy bag is created. 

Postsurgical Prognosis

After surgery, five to six bowel movements a day and one at night can be expected with a J pouch, maybe even more. Medications can be used to decrease this. Some patients may experience leakage or incontinence (inability to control bowel movements). Infection or inflammation may develop in the pouch. This can be treated effectively with antibiotics or steroids. Due to complications, about 10% of pouches must be removed and a permanent ileostomy created. 

Long Term Follow-Up

Regular follow-up medical appointments are scheduled. During these periodic visits, your physician will evaluate the function and health of the pouch. 

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