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How does Crohn’s Disease affect the gut?

Crohn’s Disease causes ulceration and inflammation that can affect the body’s ability to digest and process food. Crohn’s can develop in any part of the gut, although it is most commonly found in the ileum (the lower end of the small intestine) or in the colon. The areas of inflammation are often patchy, with sections of normal gut in between. A patch of inflammation may be small, only a few centimetres, or spread quite a distance along the gut. As well as affecting the lining of the bowel, Crohn’s may also go deeper into the bowel wall and cause abscesses or a fistula (see below).

The type of treatment recommended for Crohn’s will depend on the part(s) of the gut affected and the severity of the symptoms. It may be medical or surgical or a combination of both. For some people, especially children, nutritional therapy (using an exclusive liquid diet to treat or reduce inflammation) can be a useful option.

When is surgery necessary?

Over the last decade advances such as the development of biological drugs have produced increasingly effective medical therapies for Crohn’s Disease. There have also been changes in the way surgery for Crohn’s is now managed. For example, extensive resections (removal of diseased sections of the intestine) are now less common. However, surgery remains an important treatment option, often in combination with medical therapies. It is estimated that about seven out of 10 people with Crohn’s will still need surgery at some point in their lives.

Some of the most common reasons for surgery are outlined below.

Poor response to drug or nutritional treatment

Sometimes drug and/or nutritional therapies fail to control the inflammation and you may continue to experience symptoms such as diarrhoea, pain, poor appetite, and weight loss. Your doctor may then recommend surgery to remove any irreversibly damaged sections of intestine.

Strictures in the intestine

The inflammation from Crohn’s may cause scarring, and this can lead to a stricture (a narrowing of the space in the intestine) especially in the small intestine. This can make it difficult for food or waste matter to pass through and may cause a blockage. Symptoms of a stricture include cramping pains, distension or bloating, and, if there is a serious blockage, nausea, vomiting and constipation. You may need surgery to overcome the narrowing or blockage.

Abscesses or fistulas

Sometimes the inflammation spreads through the full thickness of the bowel wall and forms an abscess (a collection of pus). As the abscess develops it may ‘hollow out’ a chamber or hole. This can become a fistula – a channel or passageway linking the bowel to another loop of bowel, another organ such as the bladder or vagina, or the outside skin. About a third of people with Crohn’s develop fistulas (or fistulae), most commonly perianal fistulas linking the anal canal (back passage) to the skin near the anus. Fistula symptoms vary but often include leaks of faecal matter, and can be very distressing.  Abscesses can cause pain, fever and feeling generally unwell. Surgery can be used to treat both abscesses and fistulas.

Delayed growth in children

Poor absorption of nutrients combined with steroid treatment can lead to delayed growth in children with Crohn’s Disease. While this is most likely to be managed with nutritional treatment and drug therapy, it can also be helpful to remove any severely damaged sections of the intestine.

Cancer

If you have had severe Crohn’s Disease affecting all or most of the colon for at least 8-10 years, there is a slightly increased risk of bowel cancer. This may require Surgery.

Emergency problems

Emergency surgery is not often required for Crohn’s Disease, but may be needed if there is severe bleeding from the bowel, a perforation (a hole or tear in the wall of the bowel), for toxic megacolon (very severe disease of the colon), or to treat a bowel obstruction.

Which are the most common operations?

The operations most likely to be carried out for Crohn’s Disease are described below.

Strictureplasty (also known as Stricturoplasty)

This is a way of treating strictures and blockages in the small intestine which avoid removing any gut. The surgeon opens up the narrowed section of the intestine with a lengthwise cut, and then reshapes it by sewing it up the opposite way.

Food can then pass freely through the reshaped section of the intestine.

Resection

If the stricture is long, or there are several strictures close together, a resection may be preferable to a strictureplasty. In a resection the surgeon removes the damaged and diseased part of the gut, and then sews (or staples) together the ends of the remaining healthy sections. This join is called an anastomosis.

Ileocaecal resection

It is fairly common for Crohn’s Disease to affect both the terminal ileum (the last part of the small intestine) and the caecum. If the inflammation is severe and persistent, then it may be necessary to remove that part of the intestine. The healthy end of the small intestine is then joined directly to the colon (large intestine). This operation is known as an ileocaecal resection (or an ileal caecectomy).

Limited right hemicolectomy

If the first part of the ascending colon is also affected, the surgeon may remove this as well, before joining up the rest of the colon. This is a limited right hemicolectomy. (‘Hemi’ means partial).

Colectomy with ileostomy

For those with severe Crohn’s Disease in the large intestine or colon, it may sometimes be necessary to remove most or all of the colon. This operation is called a colectomy. The surgeon then brings the end of the small intestine out through an opening in the wall of the abdomen. This is an ileostomy or stoma. An external bag is fitted onto the opening to collect the waste. This can be emptied or changed as necessary.

Colectomy with ileo-rectal anastomosis

Sometimes when the rectum has remained healthy it may be possible to have a colectomy with ileo-rectal anastomosis. In this operation the colon is removed but, instead of creating an ileostomy, the surgeon joins the end of the ileum (small intestine) directly to the rectum. This operation is not advisable if the rectum is severely inflamed or scarred, or if the anal muscles have been damaged. Without a colon the faeces tend to be very liquid and people with this type of anastomosis may need to empty their bowels frequently.

Proctocolectomy and ileostomy

If the rectum is also affected by the inflammation it may have to be removed along with the colon and the anal canal, in an operation known as a proctocolectomy.

The surgeon will then create an ileostomy in the same way as for a colectomy.

Surgery for abscesses and fistulas

Abscesses may need to be lanced (opened surgically) and drained. Fistulas linking a diseased part of the small intestine with the colon are usually removed with a resection. Some perianal fistulas can be managed with an operation known as a fistulotomy, in which the fistula is opened and cleaned and left to heal up gradually. Another operation that may help a fistula to heal is the insertion of a seton.

Laparoscopy

Many of the operations outlined above, for example ileo-caecal resections, may now be carried out using laparoscopy (minimally invasive surgery). This is also known as ‘keyhole surgery’.

However, laparoscopic surgery may not be available in all centres, and may not be appropriate if you have already had abdominal surgery.

Stomas

As described above, sometimes in surgery for Crohn’s the intestine is brought to the surface of the abdomen and an opening is made so that digestive waste products (liquid or faeces) drain into a bag rather than through the anus. If the part of the intestine brought to the surface is the ileum, this procedure, and the end of the intestine connected to the opening, is known as an ileostomy. If the large intestine or colon is brought to the surface and connected in a similar way, it is a colostomy. Both types of opening are also called stomas.

Most stomas are about the size of a 50p piece, and pinkish red in colour. Because the contents of the small bowel are liquid, and might irritate the skin, an ileostomy usually has a short spout of tissue, about 2-3cm in length. Depending on the type of stoma bag used, ileostomy bags usually have to be emptied four to six times a day, and changed about twice a week. Colostomies pass firmer stool, so colostomy bags are usually emptied slightly less frequently, (about one to three times a day), and may need to be changed each time.

Are there risks to surgery?

Crohn’s Disease is a very individual condition, and the risks and benefits of different types of treatment will vary from person to person. Your IBD team should be able to help you weigh up what will be best for you.

Surgery for Crohn’s, like all surgery, will carry some general risks, such as those linked to having a general anaesthetic. There is also a small risk that some operations may lead to complications (extra problems) such as infections. Particular operations may have other risks which your surgical team will be able to tell you more about.

What are the advantages of surgery?

Depending on the operation, surgery can bring real benefits such as:

• relief from pain
• relief from symptoms such as diarrhoea or vomiting
• being able to reduce or even stop taking drugs which may be causing side effects
• the ability to eat a more varied diet and to gain weight more easily
• feeling able to lead a fuller life, for example being able to leave the house in a more relaxed frame of mind.

Many people have found that once they have recovered from their operation their quality of life is much improved. In one study looking at resection surgery from the patient’s point of view a majority of those interviewed said they wish they had had their operation earlier.

Could the Crohn’s come back after surgery?

Because Crohn’s Disease can develop anywhere in the gut, including in previously healthy sections of the small intestine or colon, surgery cannot ‘cure’ it. So, there is always a chance that Crohn’s will reoccur after the operation, either close to the operation site or in another part of the gut. It may be possible to treat these symptoms with medication, and there is some evidence that the newer biological therapies may be particularly effective in helping to treat postoperative Crohn’s. However, it could mean that another operation is necessary. Research suggests that about half of those who have an ileo-colonic resection will need another operation within 10 years. Smoking has been shown to be one factor that increases this risk of needing repeat surgery.

© Crohn’s and Colitis UK 2015