IBD IBD Surgical Management 2 — Questions and Answers
Question 1: Pouchitis after IPAA surgery is most effectively treated initially with which antibiotic?
- Vancomycin oral
- Metronidazole or ciprofloxacin (Correct answer)
- Rifaximin alone
- Amoxicillin-clavulanate
Correct answer: Metronidazole or ciprofloxacin
Acute pouchitis responds to a 2-week course of metronidazole or ciprofloxacin in approximately 80-90% of cases, making these the first-line treatment.
Question 2: Which finding on pouchoscopy is consistent with chronic antibiotic-refractory pouchitis?
- Normal appearing pouch mucosa with formed stool
- Persistent mucosal inflammation, ulceration, and edema despite ≥4 weeks of antibiotics (Correct answer)
- Pseudomembranes covering the pouch
- Single focal polyp only
Correct answer: Persistent mucosal inflammation, ulceration, and edema despite ≥4 weeks of antibiotics
Chronic antibiotic-refractory pouchitis is defined by persistent symptomatic and endoscopic inflammation despite ≥4 weeks of antibiotic therapy, requiring biologic escalation.
Question 3: Which pre-operative factor most increases the risk of complications after IPAA surgery for UC?
- Female sex
- Age under 30
- Chronic corticosteroid use (>20 mg/day prednisone) (Correct answer)
- Prior appendectomy
Correct answer: Chronic corticosteroid use (>20 mg/day prednisone)
Chronic high-dose corticosteroid use (>20 mg/day) significantly increases post-operative complications including anastomotic leak, infection, and poor wound healing.
Question 4: Why is IPAA surgery generally contraindicated in Crohn's disease?
- Technical difficulty of J-pouch construction
- High risk of pouch failure due to Crohn's recurrence in the pouch and anastomosis (Correct answer)
- Inability to achieve mucosal healing post-surgery
- Insurance coverage limitations
Correct answer: High risk of pouch failure due to Crohn's recurrence in the pouch and anastomosis
Crohn's disease in the pouch leads to high rates of pouch failure (fistulas, strictures, severe pouchitis) requiring pouch excision, making IPAA generally contraindicated.
Question 5: The Rutgeerts score (i0–i4) is used post-operatively in Crohn's disease to assess which parameter?
- Anastomotic leak severity
- Endoscopic recurrence at the neo-terminal ileum after ileocolonic resection (Correct answer)
- Quality of the J-pouch mucosa
- Severity of perianal disease
Correct answer: Endoscopic recurrence at the neo-terminal ileum after ileocolonic resection
The Rutgeerts score grades endoscopic recurrence at the neo-terminal ileum at the ileo-colonic anastomosis; i2-i4 predicts clinical relapse and guides treatment escalation.
Question 6: Which minimally invasive surgical approach is now preferred for elective colectomy in IBD when technically feasible?
- Open laparotomy through midline incision
- Laparoscopic or robotic-assisted colectomy (Correct answer)
- Single-port laparoscopy only
- Transanal endoscopic surgery (TEM)
Correct answer: Laparoscopic or robotic-assisted colectomy
Laparoscopic and robotic colectomy offer reduced postoperative pain, faster recovery, shorter hospital stay, and better cosmesis compared to open surgery in eligible IBD patients.
IBD IBD Surgical Management 2
Pouchitis after IPAA surgery is most effectively treated initially with which antibiotic?