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The following hypothetical consultation about Crohn's disease is presented for purposes of general information. If you think you have a similar condition, please see your primary care doctor to discuss your individual case and the exams and treatments that are best for you.
Doctor: Good Morning, how can I help you today?
Patient: Doctor, I'm coming to see you because I have had Crohn's disease for a long time, and my gastroenterologist seems to think that it may be time for surgery.
Doctor: How long have you had Crohn's disease?
Patient: It's been about ten years.
Doctor: Tell me what symptoms bother you the most about your disease?
Patient: I've had severe diarrhea on and off ever since I was diagnosed with this horrible disease. As if it is not bad enough to have to spend my life knowing at all times where the nearest bathroom is, I recently have been having miserable, cramping abdominal pain after eating, particularly when I eat food like fruits and vegetables, foods with a lot of roughage. Along with the pain, my belly blows-up. I haven't had vomiting, but it makes me feel nauseated and I am afraid throwing up is next. Because of this, I have lost five pounds over the last month. I don't want to eat anymore. It hurts too much.
Doctor: Have your doctors done any tests for these new problems?
Patient: Yes, they have done a small bowel x-ray series, a CT scan and a colonoscopy.
Physician reviews the films.
Doctor: Well, your x-rays show that you have the most common kind of Crohn's disease.
Patient: What is the most common kind of Crohn's disease?
Doctor: You have reached that point where you need to consider an operation. Crohn's disease affects all layers of the bowel, the inner lining called the mucosa, the middle layer called the muscular layer and the outer layer called the serosa. Crohn's disease most commonly occurs at the end of the small bowel where it joins the large bowel. That is where the X-rays show you are having your problem. After many years of recurrent episodes of disease, which we call inflammation, the small bowel thickens and the passageway for food gets smaller and smaller. Medicines help for awhile, but ultimately, the bowel wall begins to thicken and gets hard. Early in the disease, medicines can easily reduce inflammation and make you feel better. As times goes on, after many of these recurrent episodes, the bowel begins to harden like a piece of lead pipe. Once this process has reached a certain stage, that piece of bowel becomes obstructed, and will no longer allow foods to pass through. You intestinal tract gets plugged. We call this blocked or obstructed and you develop cramping and bloating, the condition where your stomach swells. I have seen this in many and I know how horrible this is.
Patient: What can be done about this problem?
Doctor: When medical therapy fails, surgery is the next step. Removal of that piece of "lead pipe" bowel can open or relieve the obstruction and make you feel better. We know that Crohn's disease cannot be cured by surgery. This is important for you to understand. Crohn's is a disease that occurs in the cells of your intestinal tract and it can affect your bowel anywhere from your lips to your rectum. Therefore, removing a piece of bowel does not cure the disease, it just removes that one particularly bad bowel segment. The disease can and often does come back. So, we no longer operate to try and "cure" this disease, but rather to deal with problematic symptoms, just like yours today. Particularly worrisome is your weight loss, which suggests that the disease has reached the point where you can not adequately nourish yourself.
Patient: What does an operation like this involve?
Doctor: Good question. I always begin these operations using minimally invasive techniques. In years past, we made a big incision to look inside your belly. Today I make small incisions and use endoscopes to look and microsurgical instruments to do the surgery. You go to the operating room and go to sleep with a general anesthetic. Then, I make three small incisions: one by your belly button, one just below your breastbone, and one just above your pubic bone. Using a lighted telescope and instruments placed through this ¼ inch small incision, I find and prepare the piece of diseased bowel that is causing your current symptoms. Next, I make an incision around your belly button, usually about a 1-1/2 inches,. Next, I move or pull the damaged bowel out through this incision, onto your abdominal wall.
Patient: You keep using the word abdominal. What does that mean?
Doctor: Sorry, that is the medical term for that part of your body that contains your stomach, your intestine, your liver and several other organs.
Patient: I always wondered what that meant. Anyway, what happens next?
Doctor: I then remove the damaged bowel and join the two ends back together and place them back inside your abdomen. When all this is finished, I close the small incisions, inject some medicine to reduce discomfort for the first 6-8 hours, and then the anesthesiologist wakes you up.
Patient: How long will I need to be in the hospital?
Doctor: You usually need to be in the hospital for 2-5 days. After this kind of abdominal surgery your intestinal tract stops working for several days. So we keep you in the hospital until your bowel function returns so you can take care of yourself when you go home.
Patient: How long will I need to be away from my normal activities like work and exercise?
Doctor: Most people need to restrict their normal activities for a week or two. Because you have an incision in your belly, I ask you not to lift heavy objects or participate in strenuous exercise for about 6 weeks.
Patient: When can I eat?
Doctor: You will be drinking fluids and eating soft foods at a week. You can begin to resume normal foods around two weeks, but probably will not be back to a normal diet for 3 weeks or so.
Patient: Are there risks to this kind of surgery?
Doctor: Yes there are, and I can tell you as much or as little as you want to know. All surgeries have risks. They include minor risks such as a stitch infection or taking longer than normal for your intestinal tract to begin working. There are more concerning risks such as infection, bleeding and scarring; problems that may require a return to the operating room and a longer hospital stay. Then there are the most serious risks. These include dying from the anesthesia or the surgery, reactive scarring in your abdomen with repeated small bowel obstructions, lung infections etc.
Patient: Well what are my chances?
Doctor: Without surgery your chances of doing well are essentially zero. With surgery 90 percent of patients do well, 10 percent do well but have some complication that prolongs the recovery and about 1 percent have a bad outcome.
Patient: I am told you are the best, but I am a little concerned that this is a teaching hospital. What does that actually mean?
Doctor: I appreciate the compliment. UC San Diego Health System is a place where we teach medical students and future surgeons. They will help me look after you and will be a great source of comfort through your surgery. The surgical residents assist at surgery. This is how they learn. They may do pieces of the surgery, but always under my guidance. The bottom line is you not only have me caring for you but a whole team of doctors.
Patient: I like that. I am tired of not eating, so how do I get this surgery scheduled?
Doctor: My nurse will get the surgery scheduled. I look forward to caring for you.
Read more about Colorectal Surgery, Gastrointestinal Surgery, Minimally Invasive Surgery and Gastroenterology at UC San Diego Health System. For more information about diagnosis and treatment of Crohn's disease, see the Inflammatory Bowel Disease Center.
Official Web Site of the University of California, San Diego.