Improved Outcomes in Colon and Rectal Surgery part 35 ppsx

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72. Penna C, Dozois R, Tremaine W et al. Pouchitis after ileal
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73. Sanborn WJ, Tremaine WJ, Batts KP et al. Pouchitis after ileal
pouch-anal anastomosis: a pouchitis disease activity index.
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76. Seow-Choen F, Tsunoda A, Nicholls RJ. Prospective randomized

trial comparing anal function after hand-sewn ileoanal anasto-
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77. Luukkonen P, Jarvinen H. Stapled vs. hand sutured ileoanal
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78. Reilly WT, Pemberton JH, Wolff BG et al. Randomized
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anastomosis. Ann Surg 1997; 225: 666–76.
79. Lovegrove RE, Constantinides VA, Heriot AG et al. A com-
parison of hand-sewn vs. stapled ileal pouch anal anasto-
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4183 patients. Ann Surg 2006; 244: 18–26.
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82. Hyman NH, Fazio VW, Tuckson WB, Lavery IC. Consequences
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85. Braveman JM, Schoetz DJ, Marcello PW et al. The fate of the
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
2
Surgery for Crohn’s disease
Jorge Canedo, Tolga Erim, and Steven D Wexner
INTRODUCTION
Crohn’s Disease (CD) is a lifelong disorder of unknown etiology
characterized by chronic focal, transmural, and granulomatosos
inflammation that can affect any portion of the gastrointesti-
nal tract. The transmural inflammation often leads to fibrosis
and to obstructive clinical presentations. Crohn’s disease was
first described by B. Crohn, L.Ginzburg, and G.Oppenheimer
in 1932 as an inflammatory condition limited to the terminal
ileum.(1) Later, Lockhart-Mummery and Morson (2) described
granulomatous colitis, and the disease process was understood
to potentially affect the large bowel. It can occur from the mouth
through the anus.
The clinical symptoms are related to the site of the disease. As it
is more prevalent among the terminal ileum and right colon, the
most frequently symptoms are: diarrhea, weight loss, abdominal
pain, and perineal disease. But the clinical features indicate the
site of the disease.(3)

a) Oral: Aphthous ulceration on the background of a mucosal
edema is the most common oral manifestation of CD.
Additional lesions described include: granulomatous masses,
chelitis, and granulomatous sialadenitis. Lesions usually coex-
ist with an intestinal disease.
b) Esophagus: Although more rare, lesions here may cause
dysphagia or pain.
c) Stomach and duodenum: Less than 5% of the patients pres-
ent with gastroduodenal Crohn’s disease; the distal antrum
and the duodenum are the most commonly affected areas.
Both sites can present as a peptic ulcer disease. In addition,
outlet gastric obstruction may occur after a healing stricture
in the antrum.
d) Small bowel: Some findings of extended involvement include
malabsorption, protein-losing enteropathy, diarrhea, anemia,
and steatorrhea. If segmental thickening or structuring devel-
ops, the patient may present with obstructive symptoms.
e) Ileocecal: Symptoms of obstruction are more frequently due
to inflammatory swelling or structuring. Transmural inflam-
mation and local sepsis often result in a palpable inflamma-
tory mass in the right lower quadrant.
f) Colon: involvement often includes the symptoms of diar-
rhea, associated with pain.
g) Perianal disease: Is common and may precede other manifesta-
tions; as a fistula, an abscess, or one or more fissures and tags.
Patients may also have systemic symptoms; fatigue, weight loss,
and fever are the primary systemic symptoms in Crohn’s disease.
Postprandial obstructed symptoms from narrowed intestinal
segments make the patient avoid eating. Weight loss may also be
related to malabsorption and, in children, may be the presenting

sign before any obvious intestinal manifestations of the disease.
Fever is common in patients with Crohn’s disease and may be
due to other chronic inflammation or due to a perforation with
associated fistula or abscess. Crohn’s disease is diagnosed most
frequently among people aged 15 to 30 years, with no differences
in prevalence between males and females. However, there is a
second peak between the sixth and seventh decades of life (4) and
diagnosis may also be made during early childhood.
Since its discovery in the Mount Sinai Hospital in New York City
almost 76 years ago, the exact cause of Crohn’s disease remains
unknown. Among many theories are genetic, immunologic,
bacterial, and bacterial antigens. The current theory about the
pathophysiology is that the intestinal flora, in conjunction with
unidentified environmental factors trigger and drives an exaggera-
dated immunologic response in a genetically susceptible host.(5)
The result is a chronic inflammation that typically extends beyond
the mucosa and throughout to the serosa. Potential risk factors to
develop CD are smoking and having first degree relatives with the
disease.(6)
EVALUATION
Symptoms of CD are heterogeneous, but most of the time include
diarrhea for more than 6 weeks, abdominal pain, and weight loss.
In most cases, the patient will have a clinic, radiologic, endoscopic,
and histological evaluation to have its diagnosis.
Crohn’s disease most often involves the distal small bowel and
proximal large bowel. Almost one half of all patients have dis-
ease that involves both the ileum and the colon. While another
one-third have disease confined to the small bowel, primarily
the terminal ileum. The clinical presentation might be divided
according to the main symptoms into:

1. Intestinal Symptoms
2. Extraintestinal symptoms
3. Biliary and Liver Manifestations
The patient with CD should undergo complete evaluation. In
most cases, the leading symptom that precipitates evaluation is
diarrhea. Eighty-five percent of patients with CD report more
than 5 bowel movements (BM) per day and weight loss as part
of the initial diagnosis.(7) The history and physical examina-
tion might uncover general complaints including weakness and
fatigue. In addition, as mentioned above, there are the specific
symptoms according to disease site.
On physical examination, paleness of the mucosa could indicate
anemia. Iron deficiency anemia occurs in up to 30% of the patients.
(8) Typically, the abdominal examination reveals abnormal bowel
sounds, detection of an abdominal mass, and pain to palpation.
Inspection of the perianal regional can provide evidence of fistula,
fissure, abscess, or skin tap. Rectal digital examination might detect
a stenosis or blood.
2
improved outcomes in colon and rectal surgery
The initial complementary evaluation starts with blood tests
and stool examination.
Blood tests
Blood tests can either provide specific or nonspecific diagnosis,
as well the general health status of the patient. The introduction
of biological therapies in IBD has renewed interest in inflamma-
tory markers (especially C reactive protein (CRP)), given their
potential to select responders to these treatments. Controversy
exists as to whether or not CRP is a useful marker, and should
be preferred in CD as it correlates well with disease activity.(9)

But a more recent study showed that neither CRP nor other
biological markers were associated with the endoscopic lesions.
(10) Elevated leukocytes and thrombocyte time can also indicate
active inflammation.
Serologic response to various microbes and autoantigens
can develop into CD. In addition to the well-established atypi-
cal perinuclear antineutrophil cytoplasmic antibodies (atypical
P-ANCA) and anti-Saccharomyces cerevisiae mannan antibodies
(ASCA), a number of new antibodies have recently been dis-
covered and data on their clinical significance has been rapidly
increasing. The combination of atypical P-ANCA and ASCA,
may be of help in patients in whom distinction between CD
and Ulcerative Colitis is not obvious with the classic diagnostic
tools (patient history, radiologic examination, endoscopy and
biopsy).
Papp et.al (11) analyzed several studies, and found that these
combinations had sensitivities of 30% to 64%, specificity more
than 90%, and PPV from 77% to 96%. Newer markers derived
from various microbial inhabitants of the gut, such as Omp,
I2, and CBir1 offer new ways to stratify patients into serologic
subgroups. Also, glycan markers including antilaminaribioside
carbohydrate antibody (ALCA) (18–38%), antichitobioside car-
bohydrate antibody (ACCA) (21–36%), and antimannobioside
carbohydrate antibody (AMCA) (28%) may play an important
role in making a CD diagnosis or prognosis.(12) More impor-
tantly, 24–44% of the CD patients found ASCA negative in
one study were positive for one or more of the antiglycan anti-
bodies. The combination of several serological markers, such
as gASCA, pANCA, and ALCA, had the best accuracy. Their
increased amounts and levels of antibody responses against

gASCA, ALCA, ACCA, AMCA and Omp were associated with
more complicated disease behaviour (44.7% vs. 53.6% vs. 71.1%
vs. 82.0%) and a higher frequency of Crohn’s disease-related
abdominal surgery (38.5% vs. 48.8% vs. 60.7% vs. 75.4%).(12)
Although the prevalence of antibodies is also higher in healthy
relatives of IBD patients than in the control population, their
role as subclinical markers is yet to be established.
Stool marker
One example of a stool marker is neutrophil determination.
However, neutrophil determination in the stool is inefficient
because of its brief lifetime. This means that the sample should
be examined within a few hours of its collection. Other exam-
ples of stool markers include calprotectin and lactoferrin. They
are produced in significant amounts in white blood cells. The
mucosal barrier is altered in CD, allowing white cells to cross
the intestinal wall. Activated leukocytes infiltrate the mucosa
and can be detected in feces. Lactoferrin is an iron-binding
glycoprotein found concentrated in the secondary granules of
the neutrophils. Granule proteins can be released from living
cells, while cell death does not appear to increase this phenom-
enon. Calprotectin is a cytoplasmic antimicrobial component
in granulocytes, monocytes, and macrophages. But besides its
promises, D’Incà et al. (13) observed that calprotectin and lac-
toferrin determination appears to reflect endoscopic and his-
tological disease activity in ulcerative colitis but not in Crohn’s
disease.
Images
In clinical practice, imaging techniques are used at initial presenta-
tion to establish a diagnosis and to assess exact location, extent,
and severity of disease at the time. These methods are also used as

follow-up during and after treatment to direct treatment strategies
and determine optimal choice and dose of medication. Patients
with established CD typically undergo many investigations over a
lifetime.
Small bowel series
The small bowel has been defined for many years as the “black box”
of the gastrointestinal system, due to its lack of endoscopic acces-
sibility. Therefore, the conventional radiological methods (small
bowel enteroclysis (SBE) (Figure 32.1a, Figure 32.1b, Figure 32.1c)
and small bowel follow through (SBFT)) were the only imaging
methods that could provide information on the morphological
features of the small bowel valuable in the diagnosis and manage-
ment of CD. Both SBE and SBFT, when performed by experienced
examiners, appear to be characterized by similar sensitivity (85–
95%) and specificity (89–94%) in detecting the radiological lesions
typical of Crohn’s disease.(14) Preference for one technique or the
other largely depends on institutional standards. Both procedures
are able to evaluate small bowel peristalsis, including the presence
of strictures and/or dilations, the distensibility of the intestinal
loops, the presence of fistulae, the morphology of circular folds,
and morphology of the mucosal surface.
Enema
For primary evaluation, endoscopy has widely replaced the bar-
ium enema (BE) as diagnostic method. However, BE can provide
important additional information in the differential diagnosis of
chronic inflammatory colonic diseases or if intestinal intubation
is not achieved at colonoscopy. The advantage of a BE over endos-
copy is a clear and reproducible demonstration of the patterns of
distribution and character of the disease as well as the detection
of fistulae.(15) With the advance of CT and MRI images, and

wireless endoscopic capsule, barium examinations not only of the
stomach but also of the colon are decreasing in frequency.
The disadvantage of the enema is the same as the one for
SBE: limited information about transmural and extraintestinal
abnormalities.
Upper endoscopy
Lemberg et al. (16) concluded the need to include EGD in the
evaluation of children suspected of having IBD. The current study

surgery for crohn's disease
found that in children with CD, 57.4% had endoscopic abnormal-
ities. These findings ranged from mild changes, such as erythema
or nodularity of the stomach, to more obvious features, such as
ulceration throughout the upper tract and cobblestoning of the
duodenum. In total, 80.3% of patients had histologic evidence
of inflammation in the upper gut; including granulomata, which
were evident in the upper gastrointestinal tract in approximately
one-quarter of patients with CD. EGD may help in the differen-
tial diagnosis in patients with indeterminate colitis after a biopsy
in the normal gastric mucosa (17) and may be used as therapeutic
intervention specifically in case of antrual or duodenual stricture.
EGD provides good relief in symptomatic patients (17).
Figure 32.1 (A) Note the string like narrowing stricture at the terminal ileum
(arrows) with proximal bowel obstruction. (X-ray courtesy of Department of
radiology Cleveland Clinic Florida) (B-C) Multiple small bowel strictures with
associated proximal obstruction. (X-ray courtesy of Department of radiology
Cleveland Clinic Florida)
(A) (B)
(C)


improved outcomes in colon and rectal surgery
Colonoscopy
Approximately 50 percent of patients have ileocolitis which refers
to involvement of both the ileum and colon, highlighting the fact
that colonoscopy with intubation of the ileum plays a fundamen-
tal role in the diagnosis and evaluation of a patient with Crohn’s
Disease. Colonoscopic findings often include segments of normal
bowel interrupted by large areas of obvious disease.
In CD, the severity of an attack is usually evaluated accord-
ing to clinicobiological variables, like the Crohn’s Disease Activity
Index. Colonoscopy has an increased risk of complication in such
cases. But Nahon et al. (18) demonstrated that colonoscopy in
severe colonic CD is useful for the diagnosis of CD versus UC.
The benefits increase if the patient is suffering from a first attack
of inflammatory bowel disease, a situation which is particularly
common in cases of severe colitis, as has been reported in 2.3–
6% of CD.(19) In this study, colonoscopy with biopsies was able
to diagnose CD after initial presentation in 50% of patients by
showing either involvement of the ileum or intervening zones
of healthy mucosa within the colon. According to Minderhound
et al. (20), colonoscopy remains the gold standard for assessment
of severity of mucosa inflammation compared to several score
indexes, as well as serum and fecal markers.
Transabdominal ultrasound (US)
Parente et al. reviewed several studies that compared the accuracy
of bowel US with other imaging techniques (barium X-ray and/
or endoscopy) and surgery in localizing CD lesions within the
bowel.(21) But many of these studies have included small num-
bers of patients with CD diseases mainly confined to the small
bowel. The overall sensitivity for diagnosis disease in the terminal

ileum is approximately 90% with specificity of 93–97%.
Bowel US has also been used to detect complications of CD.
Although the presence of abscesses, fistulae, and strictures may be
suspected from clinical history or specific complaints, it is usually
necessary to undertake endoscopy, barium studies and computed
tomography (CT) to clearly diagnose these complications. Barium
studies and CT scans are still considered the methods of choice in
detecting internal fistulae and abscesses in CD. Parente et al. in a
previous prospective study compared the sensitivity and specificity
of bowel US in detecting strictures in small bowel.(22)
Computed tomography is currently considered the nonsurgical
‘gold standard’ for the diagnosis of CD-related abscesses. Both CT
and barium studies are known for their accuracy in detecting fistu-
las, although Maconi et al. (23) demonstrated that CT or SBE alone
might miss up to 30% of the fistulas, but US alone or in combina-
tion with SBE can detect almost 90% of internal fistulas. US when
compared to CT, showed an overall high accuracy comparable in
the detection of intraabdominal abscesses. Although CT showed
a slightly greater accuracy and positive predictive value than did
US. US also has a lower sensitivity in detecting deep abscesses. This
finding can be explained by the well-known difficulties associated
with transcutaneous US examination of anatomic structures deep
in the pelvis or between the intestinal loops, especially when over-
lying bowel gas obscures the region of interest. The differentiation
between abscess and enlarged loop can be challenging.
Another feature in US is its utility in the evaluation of peria-
nal disease. Transperineal US is a simple, noninvasive and cheap
technique that can be usefully employed to study the pelvis and
perianal inflammatory diseases in static and dynamic evaluations.
Additional advantages of US are that it does not require costly or

specific diagnostic instruments and can be performed with ade-
quate training and experience in most hospitals or offices.(24)
Doppler sonography is part of the entire sonographic evalua-
tion of intestinal diseases which is helpful in estimating disease
activity, although it is not acceptable as the sole method to achieve
diagnosis.(25)
CT scan
Conventional.
Computed Tomography (CT) has usually been uti-
lized for the detection of extraintestinal complications of Crohn’s
disease (mainly intraabdominal abscesses) but is also suitable in the
evaluation of bowel wall thickness/ strictures, prestenotic dilatations
and fistulas. Nonenhanced CT scan is also used in the diagnosis of
postoperative complications indicating (intraperitoneal abscesses,
anastomotic deiscence, extraabdominal abscesses and fistulas, inci-
sional hernias, ascites, volvulus, etc.). Conventional CT is limited in
its assessment of the small bowel because of the artifact caused by
collapsed bowel loops.(26)
Enteroclysis. Because of the problems described above, CT-
enteroclysis has been great results. The ability of multislice CT
machines to image larger volumes shown (1500 to 2000 mL or
more of contrast agent delivered by the positioning of a nasojeju-
nal tube) at a faster speed with the ability to perform reconstruc-
tion after the examination, has made CTE a more feasible exten-
sion of the conventional barium enteroclysis and CT methods of
examining the small intestine (Figure 32.2). It can detect active
Figure 32.2 New CT scan technology has improved and may substitute for
standard SBS in the near future. Note the thickened bowel wall at the stricture
(solid arrows) and dilated obstructed proximal bowel (arrows with dashed lines).
Image courtesy of Toshiba America Medical systems, Inc.


surgery for crohn's disease
inflammatory changes (neutral enteral contrast with intravenous
contrast media) and complications such as fistulae, sinus tracts,
and strictures (positive enteral contrast).(27)
Volumetric. More recently, a row multidetector-computed
tomography (MDCT) has been used to perform a virtual colonos-
copy. Virtual colonoscopy studies were performed with single-
row helical CT scanners using slices of 4 mm thickness.(28) With the
advent of MDCT technology, thinner collimation (up to 0.6 mm) is
possible. It is possible now to detect flat or ulcerated lesions of the
colon, the findings of which in the evaluation of IBD correlated
highly with conventional colonoscopic findings.(29)
The disadvantages in both CT enteroclysis and volumetric
evaluation included: radiation exposure, and the need for
intravenous
Endoscopic Ultrasound(EUS)
In the setting of IBD, EUS has been limited to detecting perianal dis-
ease. The accrual of EUS, MRI, and EUA are comparable. At 85%,
87%, and 91% respectively improved upon by employing any two
methods.(30) The use in fistula disease is well described; Schwartz et
al. (31) showed that EUS may identify patients with fistulae who can
discontinue infliximab without the recurrence of a fistula.
MRI
MRI allows the accurate assessment of both inflammatory changes
of the bowel wall and extramural complications of Crohn’s dis-
ease. The noninvasiveness of this technique and its lack of ion-
izing radiation has prompted many groups to perform systematic
studies of MRI for evaluation of Crohn’s disease. Technological
advances in MRI, including the use of respiration-suspended

sequences, improved coils, fat suppression, and intravenous gado-
linium, have extended the use of MRI in the evaluation of the gas-
trointestinal tract. MRI is capable of demonstrating pathology in
both luminal and perianal Crohn’s disease. One advantage of MRI
over other modalities is its ability to differentiate active inflamma-
tion from fibrosis in a thickened bowel segment.(32) It is also safe
in pregnancy and in renal failure. Inflammatory diseases featuring
intestinal wall abnormalities, exoenteric disease manifestations
and complications, disease activity, and, to a lesser extent, mucosal
abnormalities, can be appreciated on MRI. In addition, it has been
reported that the sensitivity and specificity of MRI in assessing
disease activity are 92 and 75%, respectively.(33)
Despite closure of draining external orifices after infliximab
therapy, fistula tracks persist in some patients with varying
degrees of residual inflammation, which may cause recurrent
fistulas and pelvic abscesses. MRI can detect whether complete
fistula fibrosis occurs with complete resolution of inflammation
in the internal fistula tracks.(34)
Diasadvantages of the MRI include the high cost of the exam
and the length of time to perform it.
Double Balloon Enteroscopy(DBE)
Endoscopic examination of the entire small bowel is technically
very difficult. Push endoscopy is often possible only to the proxi-
mal jejunum. In 2001, Yamamoto and Kito developed the double
balloon method as an insertion technique for the diagnosis and
treatment of small bowel disorders.(35) DBE requires bowel prepa-
ration, sedation, radiological exposure, and a 60–100 min exami-
nation time, but is able to take biopsies and perform therapeutic
endoscopy such as endoscopic enteroclysis, hemostasis, and bal-
loon dilatation. Oshitani et al. reported their initial experience in

40 patients. Deep small bowel involvement proximal to the terminal
ileum was revealed in 27 patients, and 24 (88.9%) of these patients
had no involvement of the terminal ileum itself.(36) Another study
showed an 80% success rate of stricture dilatation.(37) This tech-
nique therefore represents a promising method for diagnosis and
therapeutic intervention of small bowel strictures in CD and may
be able to avoid surgery in such patients. However, DBE requires an
experienced and skilled therapeutic endoscopist and can be quite
confusing, and therefore costly.
Wireless Endoscopic Capsule
Wireless capsule endoscopy (WCE), initially developed for small
bowel investigations in patients with occult bleeding, has been
studied in small bowel Crohn’s disease. WCE enables a painless and
radiation-free examination of much of the small bowel in an unse-
dated patient. Based on cost-effectiveness (US$ 20,000.00–US$
30,000.00), funding issues, and the inability to obtain tissue sam-
ples, it is unlikely that WCE will soon become the primary imaging
modality used to initiate a diagnosis of Crohn’s disease or to define
its extent at relapse.(38) WCE is well-tolerated by most patients,
requires no sedation, and carries few side effects. One of the com-
plications of WCE is capsule retention. In a series of 52 patients,
Park et al. (39) reported 5 retain WEC (9.6%). Two patients (3.8%)
had to undergo a surgery for WEC removal.
With the development of the “Given Patency Capsule (Given
Imaging Ltd, Yoqneam, Israel), capsule technology might be suit-
able for cases of suspected intestinal strictures by SBE. This self-
dissolving capsule is the same size as a capsule endoscope. The
difference is found at the cellophane-walled cylinder filled with
lactose, protected by a plug with a specially-sized hole that allows
influx of intestinal fluid, which in turn dissolves the lactose in a

predetermined amount of time. If the capsule is retained in the
gastrointestinal tract, it disintegrates into small, mostly soft, frag-
ments which can easily pass through strictures. Spada et al. pro-
pective studied 27 patients with known or suspected intestinal
stricture. Twenty and two had CD. Twenty-five patients (92.6%)
retrieved the “Given Patency Capsule” in the stools, including six
of them which were dissolved. In 2 cases (7.4%), the Given Patency
Capsule could not be retrieved in stools and expulsion was con-
firmed by fluoroscopy and by a Patency Scanner. One case (4.3%)
required hospitalization due to intestinal occlusion. But in this
case, the Given Patency capsule was retrieved. The authors con-
cluded that WEC done with the Given Patency Capsule was a safe
procedure even in the presence of stricture disease.(40)
PET scan
Positron emission tomography with fluorine 18–labeled fluoro-
2-deoxy-D-glucose (FDG-PET) is a functional imaging method
used to detect abnormalities in glucose metabolism in a variety
of disorders. Neurath et al (41) studied the efficacy of PET scan
in detecting active chronic inflammation on inflamed small and
large bowel segments in CD, and compared the results to those

improved outcomes in colon and rectal surgery
obtained by hydro-MRI and immunoscintigraphy with granulo-
cyte antibodies (GABs). The sensitivity was 85%, 87%, and 71%.
The specificity was 89%, 93%, and 100%, respectively.
FDG-PET appears to be a reliable tool for detecting inflamed
gut segments in CD with higher sensitivity and specificity than
either MRI or scintigraphy.
Scintigraphy
An increased number of T cells and macrophages within the gut

lumen is a feature of CD. One of the main problems in the clini-
cal management of CD is the identification of patients undergoing
early relapse in order to ensure that appropriate preventive treat-
ment is administered. Follow-up of patients in clinical remission
is currently based on the calculations of clinical activity indexes,
together with radiological and endoscopic studies. Scintigraphy
with 99mTc-labelled interleukin-2 (99mTc-IL2) and with 99mTc-
HMPAO-labeled granulocytes (99mTc-WBC) has been evalu-
ated to detect the presence and extent of bowel inflammation in
patients with long-term inactive CD (>12 months). Annovazzi et
al compared the extent of uptake of 99mTc-IL2 and 99mTc-WBC
in patients with clinically inactive CD and, despite the absence
of symptoms, 62% had either 99mTc-IL2 or 99mTc-WBC posi-
tive for inflammation.(42) Scintigraphy with labelled white blood
cells (WBC) has been successfully used in CD patients to detect
abscesses and to assess disease extent (particularly for the small
bowel) and activity. Almer et al compared the 99mTc-WBC to
intraoperative and laparotomy findings and found a sensitivity of
85% and specificity of 81% for bowel inflammation.(43) Although
not used, scintigraphy can be an option as a noninvasive evaluation
for young children and fragile adults who might have more diffi-
culty with invasive imaging modalities. Table 32.1 summarizes the
efficacy of the exams discussed above.(41, 44, 45)
Medical therapy
The etiology of Crohn’s disease (CD) is unknown, and therefore
no curative treatments are available. The last few years have wit-
nessed a significant change in its treatment. Recent debate on
medical management of CD has focused on a step-up versus a
step-down therapy. Step-up therapy has been the traditional
treatment option where steroids and aminosalicylates are started

first, and biologics and immunomodulators are only initiated if
the patient fails to achieve remission. Step-down therapy advo-
cates use of immunomodulators and, at times, biologic agents, in
addition to or even before use of steroids and aminosalicylates, in
order to achieve remission as soon as possible. These discussions
have largely been inspired by the success of step-down therapy in
rheumatoid arthritis, success in severely ill patients and in some
part by the strong marketing efforts of the pharmaceutical indus-
try. Selection of appropriate therapy remains a decision which
must be made on an individual basis.
The ideal drug for CD should induce and maintain remission
quickly and with minimal side effects. There is no such drug right
now. Agents such as corticosteroids which are rather good at induc-
tion of remission, are not effective in maintenance. Azathioprine
and 6-mercaptopurine are the benchmark drugs for maintenance
of remission, are not as useful in induction because it takes several
months for them to be effective. The benefits of 5-ASA agents in
the management of acute CD and the maintenance of remission
are questionable.(46, 47, 48) Biologic agents such as Infliximab
and Adalimumab, which both induce and maintain remission, are
indicated only for patients considered to have moderate to severe
disease.
5-Aminosalicylates (5-ASA)
Although their benefit is at best questionable, aminosalicylates are
often used for patients with mild-to-moderate colitis. The mecha-
nism of action of aminosalicylates in CD is not fully understood.
In vitro investigation has shown many antiinflammatory and
immunosuppressive properties such as inhibition of prostaglan-
din and leukotriene synthesis, free radical scavenging, impairment
of white cell adhesion and function, and inhibition of cytokine

synthesis.
Sulfasalazine, initially approved by the FDA in 1950 for rheu-
matoid arthritis, has been used for decades in the treatment of
Ulcerative Colitis and CD. The drug is broken down by bacteria
in the colon into its two products, 5-aminosalicylic acid (5-ASA)
and sulfapyridine. These components possess antiinflammatory
(5-ASA) and antibiotic (sulfapyridine) properties. 5-ASA acts
directly on the colon and is not absorbed while sulfapyridine is
mostly absorbed by the intestine and secreted into bile and, to a
much lesser extent, into urine. Several clinical trials have shown
that Sulfasalazine is more effective than placebo at inducing remis-
sion in mild to moderate disease, greatest benefit seen in those with
colonic or ileocolonic disease. However, Sulfasalazine has a slower
onset of action than prednisone and is considerably less effective. It
is not effective as a steroid-sparing agent, and, when used as adjunc-
tive therapy, it is not more effective than prednisolone alone.
As the sulfapyridine portion of Sulfasalazine accounts for
the majority of side effects, several aminosalicylate-containing
medications have been created over the years that do not contain
sulfapyridine and are thus sulfa free. The most commonly used
drug in this class is mesalamine. Several formulations of mesala-
mine exist currently, with Asacol, Salofalk, Rowasa, and Pentasa
being the most commonly used forms. They are formulated by
either using different acrylic resins or by encapsulation in ethyl
cellulose micro granules, resulting in delivery of the drug to the
distal small bowel and colon. Other forms of mesalamine have
Table 32.1 Image tests for Small Bowel CD.
Modality Fistula Abscess Stricture Inflammation
SBE
++ - ++ ++

Colonoscopy
+ - ++ ++
US
+ + + ++
CT enteroclysis
++ ++ ++ ++
MRI
++ ++ ++ ++
WEC
- - + ++
DBE
- - + ++
PET
+ + - ++
Scintigraphy
+ - + ++
Legends: - not useful
+ somewhat useful
++ very useful

surgery for crohn's disease
been created by the dimerization of 5-ASA to make the drug
active only once it reaches the colon. Examples of these are olsala-
zine (Dipentum), which has two 5-ASAs linked together, and bal-
salazide (Colazal), which is 5-ASA linked to an inert unabsorbed
molecule. The pharmacology, and thus the undesirable drug
absorption rates, differ between these drugs, although the clinical
importance of these characteristics is debatable.(49) In general,
mesalamine compounds are better tolerated than Sulfasalazine.
However, mesalamine has not been found to be an effective treat-

ment for induction or maintenance of remission in adequately
powered, randomized, placebo-controlled trials.(48)
Antibiotics
Metronidazole and Ciprofloxacin are the most commonly used
antibiotics in treatment of CD. The mechanism of action of anti-
biotics in Crohn’s are theorized to include decreased bacterial
concentration in the gut lumen, alteration of the microflora com-
position to favor beneficial bacteria, decrease in bacterial tissue
infection and micro abscesses, decrease in bacterial translocation
and systemic dissemination. In addition, some antibiotics act as
immunomodulators.(50, 51)
These agents have not been found to be efficacious in induc-
tion or maintenance of remission. The consensus view is that these
agents should be used for perianal fistulas and postoperative man-
agement after ileocolic resection or fistula/abscess operation for
CD.(52) However, this practice is not based on adequately powered,
controlled evidence. In fistulizing Crohn’s disease, antibacterials,
immunosuppressive drugs, infliximab, and surgery are often used
in combination.
Corticosteroids
The mechanism of action for this class of drugs in CD is through
antiinflammatory activity. Corticosteroid therapy is split into
systemic versus nonsystemic types. Conventional systemic cor-
ticosteroids such as prednisone and 6-methylprednisolone have
demonstrated efficacy in induction of clinical response and remis-
sion. It has also been well established that they are ineffective in
maintenance of remission. The National Cooperative Crohn’s
Disease Study achieved 60% remission, with 0.5–0.75 mg/kg/day
prednisone tapered over 17 weeks, compared with 30% on placebo
(NNT = 3).(53) The European Co-operative Crohn’s Disease Study

achieved 83% remission with 6-methylprednisolone, 1 mg/kg/day
over 18 weeks, compared with 38% on placebo (NNT = 2).(54)
Nevertheless, approximately 50% of recipients will either fail to
respond (steroid-resistant) or will be steroid dependent at 1 year.
(55) The use of conventional systemic corticosteroids in patients
with clinically quiescent CD does not appear to reduce the risk of
relapse over a 24-month period of follow-up.(56) No dose response
trial has been performed for prednisone. Treatment is usually started
at 40–60 mg daily dose of prednisone and, once response is attained,
it is tapered down 5 mg per week. The main disadvantage of sys-
temic corticosteroid therapy is its many side effects. Corticosteroids
are associated with increased risk for infections, osteoporosis, cata-
racts, hyperglycemia, and avascular necrosis of bones.
A newer steroid therapy that is widely used for CD is budesonide.
Budesonide is a corticosteroid with high affinity for glucocorti-
coid receptors but low systemic activity due to extensive first-pass
metabolism in the liver. It has been shown to be effective in induc-
ing remission in terminal ileal and right-sided colonic disease
with significantly less side effects than systemic corticosteroids.
A meta-analysis of five published trials found that budesonide
was superior to mesalamine and placebo in achieving remission.
It was found to be similar in effectiveness to prednisone except for
those with severe disease.(57) As for maintenance, an analysis of
four double-blind placebo-controlled trials of budesonide with
identical protocols revealed that budesonide 6 mg/day is effective
for prolonging time to relapse and for significantly reducing rates
of relapse at 3 and 6 months, but its effectiveness in maintaining
remission is lost when measured at 12 months.(58)
Immunomodulators
The mechanism of action of these drugs in CD is not thoroughly

understood. The most commonly used examples are azathio-
prine (AZA) and its metabolite, 6-mercaptopurine (6-MP). AZA
and 6-MP have been researched and used successfully since 1971
in patients with CD. AZA is a prodrug that is converted to 6-MP
and then metabolized to an active metabolite, 6-Thioguanine
Nucleotide (6-TGN). 6-TGN is incorporated into ribonucle-
otides, thereby exerting an antiproliferative effect on mitotically
active lymphocyte populations. AZA and 6-MP may also possess
direct antiinflammatory properties by inhibiting cytotoxic T-cell
and natural killer cell function and inducing apoptosis of T cells
through Rac1 target gene modulation.(59) Treatment can be initi-
ated with either drug at 50 mg/kg, and doses are adjusted while
monitoring for toxicity to 1.5–2.5 mg/kg for AZA and 1–2 mg/kg
for 6-MP. They are usually administered jointly with steroids for
induction of remission due to their relatively slow onset of action;
usually 3 months or more.(60) However, they have been found to
be effective in maintenance of remission in corticosteroid-induced
remission of mild to moderate CD, and in treatment of fistulizing
disease. They are also considered to be steroid-sparing agents, an
idea supported by a meta-analysis by Pearson et al.(61)
The use of AZA in CD has evolved in the past few years with the
support of new tests which can predict its toxicity and drug activity.
Therapeutic efficacy, bone marrow suppression, and liver toxicity
of AZA and 6-MP correlate with concentrations of its metabolite
6-TGN.(62) Thiopurine methyltransferase (TPMT) enzymatically
converts 6-MP to 6-methyl-mercaptopurine (6-MMP), diverting
metabolism away from 6-TGN. There is an inverse relationship
between expression of TPMT and level of 6-TGN. Therefore,
lower TPMT activity yielding higher levels of 6-TGN has been
associated both with an increased likelihood of clinical response

and bone marrow suppression.(59) TPMT deficiency is inherited
in an autosomal recessive manner with 1 in 300 subjects having
homozygous deficiency, and around 11% of the community hav-
ing intermediate enzyme activities.(63) Measurement of TPMT
genotype has been proposed to predict the likelihood of toxic-
ity to 6-MP or AZA since patients with low TPMT activity are at
increased risk of myelosuppression.(64) The strategy of determin-
ing TPMT activity in all patients before initiating treatment with
AZA could help to minimize the risk of myelotoxicity, as patients
with intermediate TPMT activity had fourfold more risk than
high TPMT activity patients.(65) It is currently recommended
to test all patients’ TPMT levels before treating with AZA/6-MP.