Crohn's Disease - Overview

Overview

Crohn's disease can affect any part of the gastrointestinal system, from mouth to anus. A significant proportion of individuals with Crohn's disease have the terminal ileum — the end of the small bowel and the beginning of the colon — affected. Crohn's disease is an inflammation that affects all layers of the bowel and is also characterized by "skip lesions" — areas of ulceration separated by areas of healthy bowel.

Common symptoms of Crohn's disease include: diarrhea, abdominal cramping and weight loss. Other symptoms can include fatigue, perianal disease (abscesses, fissures, fistulas), nausea and vomiting, bloating or a feeling of fullness in the abdomen, and fistula formation.

Crohn's disease tends to begin in the early decades of life (and genetic influences are a likely contributing factor), though there is a second group where onset begins after the fourth decade of life.

The Crohn's Disease Support Network was established to provide peer support and information to people affected by Crohn’s disease. It is organized and facilitated by people who are living with Crohn’s disease with the help of staff from the IBD Program at Mount Sinai Hospital.

Surgical Options

Crohn's disease can affect any part of the gastrointestinal tract. Surgical options vary depending on the extent and site of the disease. The major patterns of disease are localized at the terminal ileum, small bowel and the colon.

Terminal Ileal Disease

Terminal ileal disease involves disease where the small bowel joins the colon. This disease pattern usually has symptoms of blockage such as: bloating, cramping and the inability to tolerate fibrous foods (fresh fruits, vegetables). The surgical option involves an ileocolic resection — removal of the end of the small bowel and beginning of the colon with the two ends being joined back together. If there is infection or severe inflammation in the area of bowel resection, there may be a need for a temporary ostomy to allow the joined area to rest.

Small bowel disease

Crohn's disease can occur across multiple areas of the small bowel. The diseased segments become severely narrowed resulting in symptoms of obstruction. The options include: resection (taking out the disease) and anastomosis (joining the bowel back together) or in selected patients, stricturoplasty (opening up narrowed areas without actually removing them).

Resection is generally recommend for individuals where the disease involves long segments of bowel and who have not had resections in the past.

Stricturoplasty is used for individuals with multiple short segments of disease or for individuals who are at risk of short bowel syndrome (previous multiple resections resulting in a shortened small bowel).

The decision between resections and stricturoplasty is generally made at the time of surgery, based on the status of the bowel and which option is technically feasible.

Colon disease

With Crohn's disease in the colon, the major consideration is whether or not the rectum is involved. If the colon is inflamed and the rectum is not, removing the colon and joining the small bowel or ileum to the rectum (ileorectal anastomosis) would be considered as an option. If the rectum is diseased along with the colon, the best surgical option is removing removing the rectum and colon and creating a permanent ileostomy. This procedure is known as a total proctocolectomy.

Crohn's disease can also occur in the anal region. This is known as perianal disease and can result in fistulas, fissures and abscesses. If medical therapy fails, the treatment of choice would be to remove the rectum and create a permanent ostomy. This procedure is known as a proctectomy.

Do I need a stoma?

There are several factors for a stoma in Crohn's disease. Some of which are permanent and some are temporary. A stoma is permanent if the rectum and anus are removed. Temporary stomas may be used in the following circumstances: emergency or semi-urgent operations where there is an infection in the abdomen, and a primary resection and join of the bowel is felt to be unsafe until the infection subsides; perianal sepsis or infection that requires that the stool be diverted to allow for healing and post-operative complications — such as leaks from bowel join (anastomoses). In general, as long as the rectum and anus are normal or minimally affected with disease, permanent stomas can be avoided.