Lower GI mistakes: Postop Crohn's, vaccine gaps, colonoscopy errors

Systematic prevention of postoperative Crohn’s disease recurrence, universal vaccination for herpes zoster in immunosuppressed inflammatory bowel disease (IBD) patients, and rigorous colonoscopy quality protocols emerged as key areas requiring improved clinical practice at the United European Gastroenterology Week in Berlin.

Postoperative Crohn’s Management

Eugeni Domènech Morral, MD, (Trias and Pujol University Hospital, Barcelona) noted that 40%–50% of Crohn’s disease patients undergo intestinal resection within 10 years of diagnosis, most commonly ileocecal resections. With universal prevention strategies using anti-TNF therapy or thiopurines, 30%–40% still develop endoscopic recurrence at one year, while about 20%–30% may be over treated because they would not have recurred without therapy. He contrasted three approaches—universal prevention, endoscopy-driven treatment, and selective prevention based on risk factors (for example, active smoking, prior resections, penetrating disease)—noting none has shown clear superiority, so structured monitoring is critical.

Regardless of strategy, patients should be scoped at 6 months after surgery; if no lesions are seen, repeat assessment at 18 months, suggested Dr. Morral. After an initial endoscopic check, fecal calprotectin and intestinal ultrasound can help with ongoing monitoring.

He reported favoring preventive therapy as early as when the patient resumes oral intake if prevention is chosen; his center often uses systematic prevention for high-risk postoperative patients. Antibiotics such as metronidazole may serve as short bridge therapy to slower-acting drugs, but only briefly (about three months) because of neurotoxicity risk. Meta-analytic and trial data suggest anti-TNF agents reduce endoscopic recurrence more than thiopurines, though real-world choices still depend on context and prior exposures.

Bile acid malabsorption is a frequent cause of early postoperative diarrhea after ileal resection; a small Spanish SeHCAT study found all assessed post-ileocecal patients had malabsorption, and bile-acid sequestrants were highly effective for symptom control. Small intestinal bacterial overgrowth is also common: a systematic review showed roughly tenfold higher risk in IBD, with risk increased by fibrostenotic Crohn’s and prior surgery, especially removal of the ileocecal valve. In practice, small intestinal bacterial overgrowth is often treated empirically because tests can be unreliable or hard to access after resections. 

Cobalamin (vitamin B12) deficiency is common after ileal resection. In a retrospective cohort of nearly 200 patients with ileocecal resection, about one-third received immediate prophylaxis, yet more than one-quarter still required supplementation during follow-up; resections longer than 20 cm were the only factor associated with deficiency. Practical advice from the session: measure cobalamin levels at surgery; start supplementation if deficient or if ileal resection exceeds 20 cm.

Smoking cessation is mandatory. Active smoking increases the risk of needing further resection and of postoperative recurrence, yet a Belgian survey of more than 600 patients found two-thirds were unaware of smoking-related risks in Crohn’s disease. 

Vaccination and Infection Prevention

Julien Kirchgesner, MD, (Sorbonne University, Paris) detailed serious infection risks in IBD patients receiving advanced therapies. Population-based French data including more than 200,000 IBD patients showed serious infection incidence of approximately 20 per 1,000 person-years for patients treated with anti-TNF, and he noted the order of magnitude is similar across advanced drug classes. As a patient-facing translation, that’s roughly a 20% cumulative risk over 10 years. Opportunistic infections occur at about one-tenth that rate, around 2 per 1,000 person-years. Beyond drug choice, infection risk is shaped by age, comorbidity burden, and active disease itself—effective disease control may lower risk—while class patterns exist (for example, vedolizumab’s excess more confined to GI infections). Mortality after serious infection was 4% at three months overall, but less than 1% in patients under 65 versus more than 10% in those 65 and older. Frailty was present in about 10% of patients and doubled serious-infection risk.

He noted that herpes zoster risk extends beyond JAK inhibitors: a network meta-analysis of randomized trials suggested most drugs trend toward increased risk, though not always statistically significant. The recombinant zoster vaccine, approved in the European Union in 2018, showed superior and more sustained immune responses than the live vaccine through years one to four, and real-world data suggest roughly a two-fold reduction in zoster risk with protection seen across ages and in patients on immunosuppressive drugs. In practice, for patients who develop zoster while on a JAK inhibitor, he advised briefly stopping the JAK, starting antivirals promptly, and then restarting the JAK after treatment.

IBD independently increases pneumococcal disease risk. A Danish national cohort showed risk elevation not only after diagnosis but also two to four years beforehand, supporting vaccination at diagnosis even before immunosuppression. Because serologic responses to some vaccines are blunted on immunosuppression, particularly anti-TNF for influenza, viral infection screening at IBD diagnosis is recommended to guide timely vaccination.

Regarding tuberculosis screening, he advised testing before the first advanced therapy and then reassessing for patients with frequent travel to higher-risk regions or for healthcare workers with occupational exposure, rather than at every therapy change. For Epstein–Barr virus (EBV)-naive patients, his center avoids thiopurines and prefers methotrexate if combination therapy is needed, noting that roughly 10% of 30-year-olds may remain EBV-naive.

Colonoscopy Quality and Safety

Manmeet Matharoo, PhD, (St. Mark’s Hospital, London) outlined six critical error categories in colonoscopy: patient selection, procedure planning, intubation technique, examination/withdrawal quality, communication and non-technical skills, and documentation. She noted that significant adverse events are often preceded by a chain of small slips, echoing the Swiss-cheese model of accident causation.

Patient selection should prioritize frailty and comorbidity over age alone, with explicit consideration of alternatives and a low threshold to cancel or defer when the balance is unfavorable; shared decisions may involve geriatricians or anesthesia and should be grounded in structured tools such as the BSG framework that weighs Charlson index, polyp size, and antithrombotic use with RAG ratings.

Team briefing and list “huddles” reduce error yet are often skipped; her group timed briefings at about 30 seconds to 1.5 minutes, and longer discussions typically surface safety-critical details that change management.

On insertion, perform a careful digital rectal exam and consider retroflexion to map distal pathology early. Communicate continuously under conscious sedation to maintain dignity and reduce anxiety. Consider water insertion for comfort, washing, and leak prevention, she said.

During withdrawal, use all the marginal-gains tools: position change (especially right lateral in the cecum), Buscopan as an antimotility aid, meticulous fold inspection and washing, and adequate withdrawal time to increase detection. 

Bowel preparation decisions should be individualized to the clinical question and safety: proceed with washing if the goal is cancer exclusion in a 70-year-old with borderline prep and document that significant pathology was ruled out, whereas a 40-year-old scheduled for IBD dysplasia surveillance warrants rescheduling with extended prep.

If bowel trauma is suspected, deflate and withdraw; convert to water insertion and avoid air. Non-technical skills are central: maintain situational awareness, call for help early, and debrief to address the psychological toll on the team.

Documentation is a surrogate for procedure quality and must stand alone as a clinical record. Include context, indication, anatomy-based mapping, tattoos and their location, what was done and not done, and clear follow-up recommendations—details that also aid surgeons.

"There's no such thing as a routine colonoscopy. Every colonoscopy has a potential for mistakes. And if we concentrate on getting the basics right then we have a chance to sort of improve. Mistakes will still happen, but we can minimize the clinical impact of this by doing the small things reliably each time," said Matharoo.