• Inflammatory bowel disease that shows inflammation of any portion of the GI tract from the mouth to the terminal ileum with rectal sparing. The disease is characterized by slowly progressive spread with alternating periods of remission exacerbation.
• Patients present for surgical management of problems related to the disease, such as intestinal obstruction, perirectal abscesses, bleeding, fistulas, perforation, toxic megacolon, strictures, cancers, or for management of nonrelated problems.

• The exact cause is unknown. There is some evidence to suggest that normal intestinal flora can trigger an aggressive inappropriate immune reaction in patients with a multifactorial genetic predisposition. However, no specific environment, dietary, or infectious causes have been identified (3).
• Carries a genetic predisposition as evidenced by a higher prevalence in familial twin studies (3).

• Inflammatory responses result in patchy, cobblestone, transmural inflammation of the GI tract between the mouth anus. Conversely, ulcerative colitis is continuous, mucosal inflammation, mostly in the lower intestine rectum.
  • Cytokines lead to differentiation of lymphocytes to T cells (mainly helper T cells type 1), leading to immune system activation, inflammatory response, subsequent damage of the intestinal mucosa
  • Macrophages cause granuloma formation
  • Cytokine release includes interleukin-1 (IL-1) which causes diarrhea acts as a pyrogen. Other cytokines released include IL-6, IL-8, tumor necrosis factor- (TNF-).
• Electrolyte abnormalities malnutrition occur secondary to diarrhea pain.
• Anemia occurs due to blood loss (acute or chronic) due to malabsorption of iron, vitamin B12, folate.
• Secondary peritonitis results from abscess formation that can manifest with abdominal pain. It can be acute or slow to develop, often dull, poorly localized initially. This can progress to severe pain is treated with antibiotics.
• Diagnosis can be made with a biopsy of affected tissue via endoscopy. Imaging with small bowel follow-through, CT scan, MRI can aid in diagnosis.

• Assess the severity of disease, recent exacerbations, intravascular fluid status, electrolyte abnormalities, as well as treatment medication history.
• Anesthetic plan should focus on fluid electrolyte management, assessment of anemia, use of steroids.

Exacerbations consist of diarrhea (increased frequency, fluidity, daily volume of stool), abdominal bloating, distention, discomfort, cramps particularly after meals, acute pain in the lower right abdomen, hyperactive bowel sounds, infection, blood in stool (or greasy, foul-smelling, fatty stool), nausea vomiting, weight loss, dry mouth.

Surgical resection of affected portions of the intestines

• Maintenance therapy typically includes 5-aminosalicylic acid, steroids, immunomodulators for refractory disease (azathioprine, methotrexate, infliximab) (4).
• Exacerbations are commonly treated with 5-aminosalicylic acid, glucocorticoids, antibiotics (4)

Extraintestinal manifestations include:

• Oral lesions: Aphthous stomatitis, canker sores found between the gums lower lip or along the sides or base of the tongue.
• Arthritis, including ankylosing spondylitis, can result in reduced flexibility mobility as well as joint pain. Metabolic bone disease may also be present.
• Skin disorders range from erythema nodosum (tender, red nodules that appear over the shins ankles as well as the arms) to pyoderma gangrenosum to perianal lesions (enterocutaneous fistulas, abscesses, anal fissures).
• Eye disorders: Episcleritis, uveitis, dry eyes
• Renal complications include kidney stones hydronephrosis
• Liver: Jaundice, fluid retention, primary sclerosing cholangitis

• Significant hypovolemia /or electrolyte disturbances
• Severe anemia requiring blood transfusion

• Based on severity
  • Asymptomatic remission
  • Mild to moderate
  • Moderate to severe
  • Severe fulminant
• Based on the region of bowel affected
  • Ileocolitis (involvement of the ileum colon)
  • Regional enteritis (such as ileitis or colitis)

Telemetry if the patient has severe electrolyte derangements.

• Consider epidural or patient-controlled analgesia (PCA) for postoperative pain control for large bowel resections or exploratory laparotomies.
• Avoid ketorolac NSAIDs due to metabolic bone disease.
• Consider postoperative CBC

Hyperalimentation can result in hypo/hyperglycemia, hyperchloremic metabolic acidosis, fluid overload, electrolyte abnormalities, renal hepatic dysfunction

• Ulcerative Colitis
• Insensible Fluid Losses

• 555.0 Regional enteritis of small intestine
• 555.1 Regional enteritis of large intestine
• 555.9 Regional enteritis of unspecified site

• K50.00 Crohn's disease of small intestine without complications
• K50.10 Crohn's disease of large intestine without complications
• K50.90 Crohn's disease, unspecified, without complications

rea Parsons , MD