Ulcerative colitis (UC) is an inflammatory disease potentially affecting the entire large bowel (colon and rectum). The inflammation is confined to the innermost layer of the intestinal wall (mucosa). UC can go into remission and recur. Medical management is typically the first option for treatment. If surgery is needed for UC, it is usually curative.
The most common symptoms of UC include abdominal cramping, pain, diarrhea, bleeding with bowel movements, fever, fatigue, and weight loss.
Who is at risk?
UC can appear at any age, but most patients develop symptoms in their 40s, while a smaller proportion can appear later in life (60-70 years of age). Men and women are affected equally. A family history of UC slightly increases the risk of developing it.
The exact cause of UC is unknown. Current research focuses on abnormalities in the body’s immune system and on bacterial infection. It is not contagious.
How are patients evaluated?
Initial work up includes a thorough medical history and physical examination followed by laboratory testing, complete colonoscopy of the rectum, colon and terminal ileum, and X-rays. This evaluation is important in determining the extent and severity of the disease and guides management. It can be difficult to differentiate ulcerative colitis from a similar disorder, Crohn’s disease, when the latter involves only the colon and rectum.
What is the medical treatment for UC?
Medical treatment is always the first choice unless emergency surgery is required. Several treatment plans are available for initial therapy, for maintenance therapy, and to improve the patient’s quality of life. The most commonly used initial therapy is corticosteroids combined with antiinflammatory agents. They can be either taken by mouth or as a rectal suppository, depending on the extent of the disease.
What are the available surgical treatments?
Surgery can either be scheduled immediately or at a later date. Emergency surgery is needed for a perforated bowel (hole in the bowel), severe bleeding, or a serious infection (toxic colitis). These conditions potentially threaten the patient’s life. Elective surgery is usually for UC that is not responding to medical management or when a cancerous or precancerous change is found during colonoscopy.
Because ulcerative colitis involves only the colon and rectum, complete removal of these with creation of an ileostomy is curative for the disease and is one of the treatment options.
In emergency surgery for UC, the large bowel (colon) is removed; temporarily leaving the rectum and anus, and the end of the small bowel (ileum) is brought out through the abdominal wall to the skin level to create an ileostomy through which the fecal stream is diverted. Depending upon the particular circumstances, this procedure can be performed in a traditional “open” procedure or in a minimally invasive (laparoscopic) fashion.
After the patient recovers, a second procedure can be performed to remove the remaining diseased rectum and create a new rectum (ileal pouch) using the small bowel. The new rectum is connected to the anal opening and a loop ileostomy created to protect the area until it has healed.
When healing is complete, a third procedure is done to close the ileostomy. This is the three-stage procedure for UC and ultimately results in patients being able to live without an ostomy.
In elective procedures for UC, the first and second stages of the surgery described above are combined, in either a minimally invasive or open procedure. The colon and rectum are removed and a new rectum made entirely of small intestine, usually a J-pouch, is created and connected to the anal opening. A diverting ileostomy is often created to protect the area until it heals. After the patient recovers, a second procedure is performed to close the ileostomy and reconnect the small bowel. This is the two-stage surgery for UC. Some surgeons may choose not to perform a diverting ileostomy and, therefore, this can sometimes be a one-stage procedure.
In addition to the risks associated with any surgery and those associated with pelvic surgery, surgery for UC carries a risk that a leak will develop at the surgical connections.
The surgery can be done via either a traditional open or a minimally invasive (laparoscopic) procedure. Your surgeon will help choose your procedure based on which is safest and most appropriate for you. Emergency surgery is most often an open procedure owning to the urgency of the situation.
What can I expect after surgery?
After the surgery, patients can expect five to six bowel movements a day and one movement during the night. Infection in the pouch (pouchitis) can develop but it is usually treated successfully with antibiotics. Due to complications, approximately 10% of pouches created must be removed and an ileostomy created.
What follow-up is needed after surgery?
Patients need continuing follow-up appointments with their medical provider to evaluate the function and health of the pouch over time.