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Crohn's Disease Forum » Ask the Experts » If possible, should the GI attempt to get the patient into remission prior to resection


04-22-2013, 10:03 PM   #1
David
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If possible, should the GI attempt to get the patient into remission prior to resection

I recently asked our panel of experts:
If a patient is facing ileal resection due to scarring that has caused narrowing and has active inflammation, if possible, should the GI attempt to get the patient into remission prior to resection? Does this lead to a better outcome?
Dr. Walter A. Koltun, MD, FACS, FASCRS of the Penn State Hershey Inflammatory Bowel Disease Center took time out of his busy schedule to answer this question. A little about Dr. Koltun:


Dr. Koltun is the Director of the Hershey Penn State IBD Center, Chief of the Division of Colon and Rectal Surgery, and Professor of Surgery at the Penn State College of Medicine

In regards to the question, Dr. Koltun stated:

Generally speaking, we think of intestinal disease as being either inflammatory or stricturing, with stricturing being the consequence of previous, usually repeated episodes of inflammation. Just like one would get a scar on an area of your skin that is repetitively injured with say something like a wire brush scraping the skin, similarly the intestine will scar. Over time, scars contract or shrink (that is why scars usually become less prominent with time) but in the case of a circular structure like the bowel, that scar creates a tightening of the intestinal “tube” that can result in blockage due to the scar. However, inflammation (prior to scarring) can also cause a tightening of the bowel lumen that would result in very similar symptoms by the patient. In other words, both scarring or excessive inflammation can cause pain and symptoms of obstruction, such as vomiting, abdominal bloating and a sense of feeling excessively full after eating. If the obstruction is due to inflammation, drugs that suppress inflammation, like TNF antagonists or prednisone will work. But these drugs do not work with scarring that is essentially irreversible. An operation should really be done for scarring resulting in obstructive symptoms and is uncommonly done for inflammation causing obstruction, since medicines help that. If one has both, then just a little bit of inflammation can take what is already a pretty tight, scarred down bowel, that is “just making it” with passage of food stuffs and quickly become totally obstructing. However, in such circumstances the inflammation plays a relatively small role and surgery should be done to remove the stricture.

Using antinflammatories (like low dose prednisone) is sometimes done in such circumstances to simply to keep the patient out of obstruction, allowing them to eat and maintain nutrition but get them to the operating room in a reasonable time frame to resect the scarred bowel, which is the major reason for the obstruction.
Thank you to Dr. Koltun for his time and expertise!
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