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Difficulty: MediumGastrointestinal and Abdominal Surgery

Match each clinical presentation of inflammatory bowel disease with the most appropriate definitive or initial surgical intervention.

  • A 28-year-old man with Crohn's disease presents with a single 3-cm fibrotic stricture in the jejunum causing recurrent bowel obstruction.Stricturoplasty
  • A 35-year-old man with a 15-year history of ulcerative colitis is found to have multifocal high-grade dysplasia on a surveillance colonoscopy.Total proctocolectomy with ileal pouch-anal anastomosis (IPAA)
  • A 40-year-old woman with Crohn's disease presents with a complex, draining perianal fistula that is refractory to biologic therapy, with no active proctitis.Placement of a draining seton
  • A 32-year-old man with acute severe ulcerative colitis develops toxic megacolon and clinical deterioration despite 72 hours of intravenous corticosteroids and infliximab.Subtotal colectomy with end ileostomy

Answer

The isolated short jejunal stricture requires stricturoplasty; multifocal high-grade dysplasia in ulcerative colitis requires total proctocolectomy with IPAA; the complex perianal fistula requires placement of a draining seton; and the medically refractory toxic megacolon requires a subtotal colectomy with end ileostomy.
Each matching pair correctly applies the standard surgical guidelines for inflammatory bowel disease complications based on the patient's acuity and disease distribution. Bowel conservation is prioritized in localized Crohn's strictures. Oncologic risk dictates total proctocolectomy for dysplasia in ulcerative colitis. Sphincter preservation guides perianal Crohn's management. Finally, damage control principles dictate a staged approach (subtotal colectomy first) for the emergent management of toxic megacolon.

Step-by-Step Solution

1
Evaluate the patient with the jejunal stricture.
Recognize that recurrent obstruction from a short fibrotic stricture in Crohn's disease is an indication for surgery.
Bowel conservation is paramount in Crohn's disease to avoid intestinal failure, making stricturoplasty the preferred intervention over resection for short strictures.
2
Evaluate the patient with ulcerative colitis and high-grade dysplasia.
Identify the high risk of progression to, or synchronous presence of, colorectal cancer.
Definitive prophylactic and therapeutic management requires removal of the entire large intestine and rectum via total proctocolectomy with IPAA.
3
Evaluate the patient with the complex Crohn's perianal fistula.
Determine the need for surgical drainage while strictly preserving continence.
Seton placement prevents premature closure of the external tract and recurrent abscess formation without dividing the anal sphincter muscle.
4
Evaluate the patient with toxic megacolon failing medical management.
Recognize the need for emergent, life-saving surgery using damage-control principles in a critically ill, unstable patient.
Subtotal colectomy with end ileostomy removes the colon while leaving the rectum in situ, avoiding a lengthy, morbid pelvic dissection and risky primary anastomosis.

Key Concept

Surgical management of Inflammatory Bowel Disease (IBD) complications
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Topics

Gastrointestinal and Abdominal Surgery

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