Irritable Bowel Disease - Crohn's Disease and Ulcerative Colitis
Guest: Dr. Kerry Hammond - Surgery
Host: Dr. Linda Austin – Psychiatry
Dr. Linda Austin: I am Dr. Linda Austin. I am interviewing Dr. Kerry Hammond who is Assistant Professor of Surgery at the Digestive Disease Center at the Medical University of South Carolina. Dr. Hammond, let’s talk, in this podcast, if we could, please, about resection of the colon for inflammatory bowel disease. Talk, first, a little bit about what that syndrome is, what the symptoms are.
Dr. Kerry Hammond: The two most common forms of inflammatory bowel disease would be Crohn’s disease and ulcerative colitis. Most of the medical treatment for those syndromes is usually directed by the medical gastroenterologists, such as the gastroenterology team at MUSC. Often I am referred patients for complications or part of the progression of those diseases that, ultimately, may require surgery.
There are several reasons why a patient may end up needing to have surgery if they have a diagnosis of Crohn’s or ulcerative colitis. Typically with Crohn’s disease, surgery may be necessary in a more urgent setting. If there is a stricture in the bowel that leads to an obstruction or if there is a perforation of the bowel, that would require an urgent surgery to fix.
Dr. Linda Austin: So, it sounds, then, as if sometimes these may be elective or planned surgeries and other times they may be emergent surgeries, I would imagine, if there is a perforation?
Dr. Kerry Hammond: Right. There are emergent and elective indications for surgery. Patients with Crohn’s disease, sometimes, have a more chronic stricturing process that can be controlled with medications for a long time. If those medications cease to give a good result, then we would consider doing surgery to remove that strictured area of bowel.
Dr. Linda Austin: What are the symptoms of perforation?
Dr. Kerry Hammond: The symptoms of perforation, a patient would have severe abdominal pain and probably nausea and vomiting as well as some fever. Certainly a patient with Crohn’s disease, with these symptoms, should be evaluated in an emergency room.
Dr. Linda Austin: Immediately? It sounds like it is a very dramatic presentation.
Dr. Kerry Hammond: It usually is. It can, however, be a bit of a blunted response with symptoms in patients that have been on steroids for a long time because the steroids can decrease the ability of the body to sense pain.
Dr. Linda Austin: Now, in an earlier podcast, we talked about two different approaches to doing colon resection, one being laparoscopic, which is minimally invasive, and the other being the more traditional open incision, open resection. Do you tend to one or the other for inflammatory bowel disease?
Dr. Kerry Hammond: That, again, is variable for each patient and each reason that we are doing surgery. Usually in a more urgent situation, such as a perforation, I, myself, would tend to do an open surgical approach to that. However, for an elective resection for stricture, secondary to Crohn’s disease, laparoscopic technique can be a very appropriate way to do that.
Dr. Linda Austin: I would guess you must start off by doing fairly detailed anatomic studies, is that right, imaging studies? Can you describe that?
Dr. Kerry Hammond: Certainly. The patients with Crohn’s disease and ulcerative colitis should be followed by their gastroenterologist. When symptoms such as obstruction are occurring, the gastroenterologist may choose to do a colonoscopy as well as one of several studies that are available to look at the upper portion in the GI tract. One of these is what we refer to as an upper GI swallowing study in which the patient would swallow a contrast material, such as barium, and then x-rays are taken every so often to see how far that contrast is going through the bowel. This lets us see if there is a narrowed area in the bowel.
Dr. Linda Austin: Let’s talk some, now, about surgery for ulcerative colitis. What are the indications for surgery?
Dr. Kerry Hammond: Unlike Crohn’s disease, ulcerative colitis, which is a second form of inflammatory bowel disease, can actually be cured by surgery. The treatment, typically, is to remove the entire colon and rectum. In this era, we have the capability to do what is commonly referred to as a J-pouch procedure. So, when we remove the entire colon and rectum, rather than, most, patients having to have a permanent ileostomy, we are able to create a reservoir out of the small intestine and hook that to the anal opening and this allows defecation through the normal route, through the anus.
Surgery for ulcerative colitis is something that we consider when medications are no longer controlling the patient’s symptoms. If symptoms are increasingly affecting the patient’s quality of life and they are not responding to medications further, then we consider doing a surgical resection. Also, ulcerative colitis is associated with an increased risk of cancer and this cancer risk starts to go up about eight years after the diagnosis of ulcerative colitis. Patients should undergo surveillance colonoscopies with biopsies annually with a diagnosis of ulcerative colitis.
In circumstances where these biopsies show dysplasia, which is a precursor to the development of cancer, then we also would consider removing the colon as a preventative measure to prevent cancer from developing.
Dr. Linda Austin: It sounds like it is a big procedure on the one hand and yet, for patients who have suffered for many years, it must feel like a blessing.
Dr. Kerry Hammond: Yes.
Dr. Linda Austin: Dr. Hammond, thanks so much for talking with us.
Dr. Kerry Hammond: Thank you.
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