Terminal ileal Crohn's disease: conservative surgeon and aggressive physician?

The timing of surgery in Crohn's disease is a matter of continuing debate, in particular early surgery for patients presenting with apparent appendicitis found to have terminal ileal Crohn's. Our aim was to assess the current strategies of UK Consultant Coloproctologists and Gastroenterologists in managing terminal ileal Crohn's disease in acute and elective settings.

A postal questionnaire survey was sent to 460 Consultant members of the Association of Coloproctology of Great Britain and Ireland (ACPGBI) and a very similar 'medical' questionnaire sent to 1043 Consultant British Society of Gastroenterology (BSG) members.

247 ACPGBI members (54%) replied to the 'surgical' questionnaire. For acute terminal ileitis at presumed appendicectomy 40% would recommend doing nothing, 33% a limited ileal/ileo-caecal resection and 27% appendicectomy only. For elective management of terminal ileal Crohn's, 51% would institute medical therapy and refer to a gastroenterologist, 40% would refer directly to a gastroenterologist while 9% would follow up the patient themselves. No surgeon would perform primary resection. 398 BSG members (38%) responded to the 'medical' questionnaire. 54% would prefer their surgical colleagues to perform ileo-caecal resection acutely patients operated on for presumed appendicitis. Electively only 1.8% would refer for surgery as primary therapy. Most would institute medical therapy, with the therapeutic options varying widely.

There is divided opinion on managing the acute presentation of terminal ileal Crohn's disease. Surgeons appear more conservative in their approach compared to gastroenterologists. This merits further clarification before acceptance amongst the majority of physicians and particularly surgeons.