General Surgery · Year 3 · from General Surgery

Case 2: Small Bowel Crohn's Disease Requiring Surgery

Patient Demographics

  • Age: 34 years
  • Sex: Male
  • Occupation: Graphic designer

Chief Complaint

"I've been having severe abdominal pain and can't eat without pain for weeks."

History of Present Illness

The patient has a 10-year history of Crohn's disease, primarily involving the terminal ileum. He has been on various medications over the years. His disease has been increasingly difficult to control, with frequent flares. Over the past 2 months, he has developed persistent right lower quadrant pain, worse after eating. He has lost 8 kg despite trying to maintain nutrition. He has had near-obstructive symptoms with nausea and intermittent vomiting. His current medications have failed to control his symptoms.

Past Medical History

  • Crohn's disease (10 years)
  • Multiple flares requiring hospitalization
  • Currently on adalimumab (started 2 years ago)
  • Prior treatment with infliximab (lost response)
  • Perianal disease (history of abscess, now healed)
  • No prior abdominal surgery
  • Depression

Medications

  • Adalimumab 40 mg every 2 weeks (subtherapeutic drug levels)
  • Prednisone 20 mg daily (for current flare)
  • Budesonide 9 mg daily
  • Azathioprine 150 mg daily
  • Multivitamins, iron, vitamin B12

Laboratory Results

  • Hemoglobin: 10.2 g/dL
  • Albumin: 2.8 g/dL
  • CRP: 48 mg/L (elevated)
  • Fecal calprotectin: >1000 μg/g (markedly elevated)
  • Vitamin B12: Low
  • Iron studies: Iron deficiency

Imaging

MR Enterography:

  • Marked wall thickening of terminal ileum (15 cm segment)
  • Luminal narrowing with pre-stenotic dilation
  • Stricture with upstream dilation
  • Mucosal enhancement and edema
  • Small mesenteric phlegmon
  • No drainable abscess

CT Abdomen/Pelvis:

  • Confirms MRI findings
  • Near-complete obstruction at terminal ileum
  • No perforation or abscess

Colonoscopy (limited):

  • Unable to intubate terminal ileum due to stricture
  • Mild colonic involvement
  • Biopsies: Chronic active inflammation consistent with Crohn's

Multidisciplinary IBD Conference

  • Failed multiple biologics with progressive stricturing disease
  • Near-obstructing stricture unlikely to respond to medical therapy
  • Malnutrition requiring optimization
  • Surgical consultation recommended

Preoperative Optimization

  1. Nutritional support: TPN initiated for 2 weeks
  2. Steroid management: Stress-dose steroids perioperatively, then taper
  3. Hold biologics: Adalimumab held 4 weeks before surgery
  4. Anemia: Iron infusion, hemoglobin improved to 11.5 g/dL
  5. DVT prophylaxis: Given IBD is a hypercoagulable state
  6. Smoking: Patient is a non-smoker (good prognostic factor)

Operative Procedure

Laparoscopic ileocolic resection:

  • Identified diseased terminal ileum (20 cm strictured segment)
  • Preserved maximum bowel length
  • Resected diseased terminal ileum with small cecal cuff
  • Stapled side-to-side, functional end-to-end ileocolic anastomosis
  • No evidence of other skip lesions

Pathology

  • Terminal ileum: Transmural inflammation, fibrosis, stricture
  • Consistent with Crohn's disease
  • Margins: Microscopic inflammation present (common in Crohn's)
  • No dysplasia or malignancy

Postoperative Course

  • Diet advanced POD 3
  • Discharged POD 5
  • Steroids tapered over 8 weeks
  • GI follow-up for postoperative medical therapy

Postoperative Medical Management

  • Given high-risk features (young age, prior biologic failure, perianal disease):
  • Started ustekinumab 6 weeks postoperatively
  • Goal: Prevent/delay endoscopic recurrence

Surveillance

  • Colonoscopy at 6 months post-surgery (Rutgeerts score)
  • Fecal calprotectin monitoring

Teaching Points

  1. Surgery is not "failure" in Crohn's - it's part of disease management
  2. Indications: Stricture, perforation, abscess, medically refractory disease
  3. Bowel-sparing surgery (limited resection) is the goal
  4. Strictureplasty an option for non-phlegmonous strictures
  5. Postoperative biologic therapy reduces recurrence
  6. Smoking is the strongest modifiable risk factor for recurrence

Clinical Image

Image Description: MR enterography demonstrating terminal ileal wall thickening with luminal narrowing and upstream dilation characteristic of stricturing Crohn's disease. The "comb sign" of engorged vasa recta indicates active inflammation.

Attribution: Image from Wikimedia Commons. Source: https://commons.wikimedia.org/wiki/Category:Crohn%27s_disease

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