IBD Surgical Indications Algorithm (ASCRS)

Adult with UC or Crohn's disease: is surgery indicated?

Decide with the IBD multidisciplinary team (gastroenterology and colorectal surgery). Involve surgery early in moderate to severe disease.

Which disease: UC or Crohn's?

UC: what is the indication for surgery?

UC emergency or urgent: total abdominal colectomy + end ileostomy

For fulminant UC, toxic megacolon, perforation, refractory bleeding, or acute severe UC not responding to IV steroids and rescue therapy. Leave the rectum in situ. Decide on pouch or other reconstruction later, after recovery.

After any UC operation: VTE prophylaxis, leak watch, surveillance

Consider extended chemical VTE prophylaxis after discharge, unless there is active bleeding or a high bleeding risk. After IPAA, look early for anastomotic leak (pelvic sepsis). Keep endoscopic surveillance of any retained rectum or pouch.

UC dysplasia or cancer: MDT; proctocolectomy if not removable endoscopically

Proctocolectomy (with or without IPAA) for high-grade dysplasia or worse, persistently invisible or multifocal dysplasia, dysplasia not fully removable endoscopically, or any dysplasia with PSC. Visible low-grade dysplasia fully removed endoscopically: close surveillance.

UC refractory to medical therapy: elective proctocolectomy

For chronic active disease despite medical therapy, steroid dependence, or intolerance of therapy. Discuss both options: restorative (IPAA, J-pouch) and non-restorative (end ileostomy).

Crohn's: what is the indication for surgery?

Crohn's emergency: operate

Free perforation: resect the perforated segment (not simple repair). Severe colitis not responding to medical therapy: total abdominal colectomy + end ileostomy. Bleeding with instability despite resuscitation: operate; targeted resection if the source is found.

After any Crohn's operation: plan medical therapy to prevent recurrence

Agree postoperative medical therapy with gastroenterology to treat residual disease or maintain remission. Support smoking cessation. Give VTE prophylaxis in hospital (IBD raises VTE risk) unless there is active bleeding.

Crohn's stricture: small bowel (including duodenum) or colon?

Small bowel, duodenal or anastomotic stricture: dilate, stricturoplasty, resect

No stricturoplasty with perforation, inflammatory mass, cancer, dysplasia or severe malnutrition. Inflammatory stricture: medical therapy first. Short (under 5 cm) fibrotic stricture without abscess or fistula: endoscopic balloon dilation. Dilation fails or unsuitable: limited resection (about 2 cm margins) or stricturoplasty to save bowel length.

Colonic stricture: colonoscopy with multiple biopsies first

2% to 6% of colonic Crohn's strictures contain dysplasia or cancer. If the stricture cannot be fully assessed endoscopically: resect by oncological principles. Colonic stricturoplasty is generally discouraged.

Crohn's abscess or fistula: control sepsis first

Start anti-TNF only after antibiotics and drainage. Intra-abdominal abscess: IV antibiotics; percutaneous drainage if large (under 3 cm: antibiotics alone may do). Then interval resection or medical therapy. Enteric fistula that persists despite medical therapy: resect the diseased bowel.

Crohn's refractory to medical therapy: resect by site

Ileocolic or small bowel: limited resection with about 2 cm margins, by MDT; early resection is an option in limited non-stricturing ileocaecal disease. Colon with rectal sparing: segmental colectomy (one segment) or total colectomy + ileorectal anastomosis. Rectal disease: proctocolectomy + end ileostomy.

Crohn's dysplasia or cancer: MDT; total colectomy or proctocolectomy

Visible dysplasia fully removed endoscopically: surveillance. Dysplasia not removable endoscopically, also in flat mucosa, multifocal, or cancer: total colectomy or proctocolectomy by oncological principles.