A Rare Presentation of Crohn's Disease

sis, a delay in surgery for presurgical nutritional
restoration may be detrimental, especially because
the benefit of presurgical nutrition is unproven in
prospective studies.(5) Therefore an emergency
surgery is warranted.

Resection is the procedure of choice for Crohn's
ileitis. Most commonly, the disease involves the ter-
minal ileum and caecum requiring ileocecal resec-
tion. When caecum is spared and adequate length of
healthy ileum, approximately 7-10cm proximal to
ileocecal valve remains, an ileal resection with end-
to-end ileal anastamosis can be performed. This pre-
serves the ileocecal valve and helps to minimize di-
arrhea post-surgically.(6)

A study by Fazio et al (7) resolved the controversy
regarding optimal margin width at resection of
Crohn's disease. It showed that large margins are
not beneficial and there was no statistically signifi-
cant difference in recurrence rates between patients
with histologically involved and uninvolved margins.
However, the surgeon has to choose the line of re-
section based on intraoperative assessment of ex-
tent of disease. Proximal level of involvement is de-
termined by palpation of mesenteric border of the
bowel. In involved areas, the phenomenon of fat-
wrapping (or fat hypertrophy), a feature peculiar to
Crohn's disease (8) will obscure the bowel wall,
which becomes palpable when normal intestine is
reached. A few centimeters away from this point will
be an appropriate line of resection and small apht-
hous ulcers seen inside the bowel lumen shall not
require further extension of resection.(6)

The technique of intestinal anastomosis in Crohn's
disease has been a matter of debate for quite some-
time. A longer side-to-side anastomosis may be ben-
eficial over an end-to-end anastomosis as it is be-
lieved that a large caliber anastomosis will take long
time to produce stenosing obstruction. However,
published data to date does not show superiority of
one particular type of intestinal anastomosis.(9)
Anastomosis can be hand-sewn or performed with a
stapler. Under appropriate conditions like minimal
peritoneal contamination in a patient with hemody-
namic stability and good nutrition, resection and pri-
mary anastomosis is a safe procedure with a leak
rate of less than 1 percent.(10) Nevertheless, in high
surgical risk candidates and patients with free
colonic perforation or fulminant peritonitis, resec-
tion with proximal ileostomy is the treatment of
choice.(11) Primary closure of the perforation is ab-
solutely contraindicated under any circumstances.

As no single surgery for Crohn's disease is curative,
these patients always have a very high risk of recur-
rence, the prevention of which should be in the
mind of every surgeon operating on Crohn's disease.
Young age, short disease duration and perforating
disease are risk factors for early postoperative recur-
rence.(12) Unfortunately, our patient had all these
risk factors. There is evidence to suggest the use of
some types of medical therapy to prevent both en-
doscopic and symptomatic recurrence of Crohn's
disease after surgery. Besides being inappropriate
for maintenance therapy in nonsurgical Crohn's pa-
tients, steroids have proved inefficient for prophy-
laxis against disease recurrence. Although there is
evidence and support for the efficacy of other 5-
acetylsalicylate preparations in the maintenance of
postsurgical remission, the overall beneficial effect
of mesalamine is small. Only a modest benefit has
been shown with azathioprine and 6-Mercaptop-
urine. But since there is much stronger evidence
supporting their use in maintenance therapy after
medically-induced remission, their use is probably
justified in high-risk post-operative patients.(13) Fi-
nally, smoking cessation is strongly advocated in all
post-operative patients as it has been found that
smokers have double the rate of recurrence.(13)

We wish that the above-mentioned facts will be
helpful for surgeons in intraoperative decision mak-
ing when such a rare cause of ileal perforation is en-
countered. We conclude by stating that a team with
a conservative surgeon and an aggressive physician
will be ideal for optimal management of Crohn's dis-
ease.

References:

1. Mekhijan HS, Sweitz DM, Watts HD et al. Nation-
al cooperative Crohn's disease study: Factors de-
termining recurrence of Crohn's disease after
surgery. Gasteroenterology 1979;77:907-913.

2. Fazio VW, Wu JS. Surgical therapy for Crohn's
disease of the colon and rectum. Surg Clin
North Am 1997;77:197-210.

3. Tomaszczyk M, Zwemer DA. Int Surg 2005;90(3
Suppl):S45-7.

4. Veroux M, Angriman I, Ruffolo C et al. Minerva
Chir 2003;58(3):351-4.

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