From the Guidelines
Surgical emergencies in patients with inflammatory bowel disease (IBD) include perforation, severe peritonitis, massive intestinal bleeding, obstruction, toxic megacolon, and severe colitis non-responder to medical treatment, which require immediate surgical intervention to reduce morbidity and mortality risks 1. These emergencies can present with severe abdominal pain, fever, tachycardia, and laboratory abnormalities, and initial management includes fluid resuscitation, broad-spectrum antibiotics, bowel rest, and prompt surgical consultation.
- The most critical surgical emergencies in IBD patients are:
- Perforation and severe peritonitis
- Massive intestinal bleeding
- Obstruction
- Toxic megacolon
- Severe colitis non-responder to medical treatment
- Laparotomy is recommended in hemodynamically unstable patients, while a laparoscopic approach is recommended in hemodynamically stable patients to decrease morbidity and length of hospital stay 1.
- Subtotal colectomy with ileostomy is recommended in patients with acute severe refractory colitis, non-responders to medical treatment, in a laparoscopic or open approach according to patient’s hemodynamic stability 1.
- Early recognition and intervention are crucial as these complications carry significant morbidity and mortality risks, particularly in patients on immunosuppressive therapies who may have blunted inflammatory responses masking the severity of their condition.
- The management of these emergencies should be guided by the principles of damage control surgery, with consideration of the patient's hemodynamic stability and the surgeon's skill, as outlined in the WSES-AAST guidelines 1.
From the Research
Surgical Emergencies in IBD
The following are surgical emergencies that can occur in patients with Inflammatory Bowel Disease (IBD):
- Toxic colitis
- Hemorrhage
- Perforation
- Intra-abdominal masses or abscesses with sepsis
- Intestinal obstruction 2
- Acute obstruction
- Massive hemorrhage
- Acute abscess 3
Management of Surgical Emergencies
The management of these emergencies should be individualized based on patient age, disease type and duration, and patient goals of care 3.
- Toxic colitis and perforation are best managed with intestinal resection and fecal diversion 2
- Hemorrhage in ulcerative colitis initially requires colectomy with rectal preservation and ileostomy 2
- In Crohn's disease hemorrhage is often focal and localization and segmental resection are performed 2
- Intra-abdominal abscesses should initially be attempted by computed tomography-guided percutaneous drainage followed subsequently by definitive resection 2
- Intestinal obstruction should be initially managed nonoperatively, with surgery reserved for complete obstruction or intractability 2