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.
Men and women are affected equally and people of all ages can develop UC. A family history of UC slightly increases the risk of the disease.
The exact cause of UC is unknown, but it is not contagious. Potential causes include immune system abnormalities and bacterial infection.
Most patients develop symptoms in their 40s. A smaller number experience symptoms for the first time later in life (ages 60 to 70). The symptoms of UC are similar to Crohn’s disease, when the latter only affects the colon and rectum. The most common symptoms of UC include:
The first step is to undergo a thorough medical history and physical exam. Following this, additional testing may be needed. This may include blood tests, a complete colonoscopy of the rectum, colon and terminal ileum (the end of the small intestine that intersects with the large intestine), as well as x-rays. This evaluation helps determine the extent and severity of UC, rules out other diseases such as Crohn’s disease, and guides management.
Medical treatment is always the first choice unless emergency surgery is required. The goal of medical therapy is to improve a patient’s quality of life. Initially, the most common therapy is corticosteroids (steroid hormones) combined with anti-inflammatory agents. Based on the extent of the disease, these are taken orally or as a rectal suppository.
Surgery is considered for patients when medical management is no longer effective. Other reasons that a patient may require surgery include cancer or precancerous lesions that are found during colonoscopy. Sometimes surgery needs to be performed when a complication of the disease occurs such as a perforated bowel (hole in the bowel), severe bleeding or serious infection (toxic colitis).
Since UC involves only the colon and rectum, complete removal of both may be done in some cases. This treatment option is curative, but requires an ileostomy. Some patients may be candidates for a J-pouch. This procedure involves the removal of the entire colon and all of the rectum with the exception of the last section where the sphincter muscles are located. The small bowel is then used to create a “new” rectum (the pouch) which is attached just above the sphincter muscles. The patient will have a temporary ileostomy during the healing period however ultimately this will be taken down and the patient will be able to pass stool through their anus again.
Elective and emergency surgeries can be performed through traditional “open” procedures or minimally invasive (laparoscopic) approaches depending on the circumstances. The safest, most effective approach is determined on an individual basis.
Because emergency surgery is done for potentially life threatening conditions, it is most often done as an open procedure. During emergency surgery, the large bowel (colon) is removed. The rectum and anus are left in place temporarily. The end of the small bowel (ileum) is brought out through the abdominal wall to the skin level. An ileostomy is created through which fecal matter is allowed to empty into a bag attached to the skin.
After recovery, a second procedure can be performed. During this surgery, the diseased rectum is removed. A new rectum (ileal pouch) is created using the small bowel. The new rectum is connected to the anal opening. A loop ileostomy is created to protect the area until it has healed.
When healing is complete, a third procedure is done to close the ileostomy. This three- stage UC procedure ultimately results in patients being able to live without an ileostomy.
In elective surgery, the first and second stages described above are combined. This is the two-stage surgery for UC, done through a minimally invasive or open procedure. Both the colon and rectum are removed. A new rectum or J-pouch is made from the small intestine and connected to the anal opening. A diverting ileostomy is often made 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. In select cases, some surgeons choose not to create a diverting ileostomy, which results in a one-stage procedure.
After surgery, five to six bowel movements a day and one at night can be expected. Infection may develop in the pouch. This is usually treated effectively with antibiotics. Due to complications, about 10% of pouches must be removed and an ileostomy created.
LONG TERM FOLLOW-UP
Regular follow-up medical appointments are scheduled. During these periodic visits, your physician will evaluate the function and health of the pouch.