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case report

CROHN’S
ILEO-COLO-PROCTITIS

BY.ABRAR HUSSAIN ZAIDI


An emergency
call from medical ward
Aug.2006
Patient’s profile
Young soldier 30 years of age
Admitted to medical ward
3rd admission day
Presentation

Severe diarrhea 10 -15


motion /24hrs --- one week

Previously treated by Hakim sahib


for ill-defined abdominal pain and
intermittent diarrhea -for six
months
Examination
Acutely ill,toxic
malnourished
young man in early thirties.
Examination
Abdomen
Distended and tender all over
BS -ve.
P/R
Blood mixed loose stools
Acutely inflamed and congested
Mucosa/ulceration
Loss of normal mucosal configuration
X-ray Abdomen

Markedly Distended loops of gut


[>8 cm ]
Impression

Toxic Mega-colon
Enterocolitis
uncertain etiology
Patient in need of
emergency surgical intervention
Indication
for surgical intervention

FAILURE OF
CONSERVATIVE TREATMENT-WITH
48 HOURS OF OBSERVATION
MAJOR
PRE OP CONCERNS
Severe toxaemia
Weight loss/ malnutrition
Anaemia

SEVERE DISEASE
Operative findings
Large gut wall- Inflamed,
Extremely friable from caecum to
rectum

Finger would easily dip into the


lumen where ever pressed.

Distal ileum [ 2ft] also inflamed


Surgical Procedures

TOTAL COLECTOMY [ rectum preserved]


LIMITED ILEAL RESECTION
ILEOSTOMY
RECTAL MUCOUS FISTULA

Ileorectal anastomosis –not considered


safe
In the presence of severe rectal disease
DIFERRENTIAL
DIAGNOSIS

NON SPECIFIC ENTEROCOLITIS


ULCERATIVE COLITIS
CROHN’S DISEASE
DIAGNOSIS
CROHN’DISEASE

Based on
PER OPERATIVE FINDINGS
HISTOPATH REPORT
Post- operative course
Wound sepsis
Burst abdomen
Continuous retrograde rectal discharge
Subphrenic abscess
Bil pleural effusion/pneumonia
Nutritional debilitation
Addiction to opeiods
MAJOR
POST OP PROBLEM
PROFUSE DISCHARGE
FROM RECTAL STUMP –
PERSISTENT RECTAL DISEASE

PERSISTENT INCISION WOUND


SEPSIS
ADDED PROCEDURE
6th week post op

ANAL SPHINTEROTOMY
ANAL SUMP SUCTION
DRAINAGE

INCISION SITE HEALING -----WITH


SCARRING
SUBSEQUENT/SECOND
MAJOR CONCERN

MULTIPLE
ENTEROCUTANEOUS
FISTULAE
2nd ADDED PROCEDURE
10th week post op

REPEAT LIMITED RESECTION OF


ILEUM

MAKING A SAFE APPROACH TO


DISAESED ILEUM ---- A PROBLEM
APPROACH
12th WEEK post op

REMARKABLE RECOVARY
Weight gain, wound healing
ONGOING PROBLEM

PERSISTENT RECTAL DISEASE

REPAEATED RECTAL BIOSIES SHOW


PERSIST CHRONIC INFLAMATION OF
RECTUM
FUTURE CONCENS

WHEN AND HOW TO


RE-ESTABLISH
THE NORMAL FAECAL ROUTE
YOUR SUGGESTIONS