Ulcerative Colitis

                                                                                                                   

What is Ulcerative colitis?

Ulcerative colitis is an inflammation of the lining of the large bowel (colon). Symptoms include rectal bleeding, diarrhoea, abdominal cramps, weight loss, and fevers. In addition, patients who have had extensive ulcerative colitis for many years are at increased risk of developing large bowel cancer. The cause of ulcerative colitis remains unknown.

How is Ulcerative colitis treated?

Initial treatment of ulcerative colitis is medical, using antibiotics and anti-inflammatory medications (drugs such as Asacol, Prednisolone etc). These are usually necessary on a long-term basis. Prednisolone has significant side effects, and therefore, it is usually used for short periods. “Flare-ups” of the disease can often be treated by increasing the dosage of medications or adding new medications, such as 6-Mercaptopurine. Hospitalisation may be necessary to put the bowel to rest.

When is surgery necessary?

Surgery is indicated for patients who have life threatening complications of inflammatory bowel diseases, such as massive bleeding, perforation, or infection. It may also be necessary for those who have the chronic form of the disease, which fails to respond to medical therapy. It is important that the patient is happy that all reasonable medical therapy has been attempted prior to considering surgical therapy. In addition, patients who have long-standing ulcerative colitis and show cancer signs may be candidates for removal of the colon, because of the increased risk of developing cancer. More often, these patients are followed carefully with repeated colonoscopy and biopsy, and only if precancerous signs are identified is surgery recommended.

What operations are available?

Historically, the standard operation for ulcerative colitis has been removal of the entire colon, rectum and anus. This operation is called a proctocolectomy and may be performed in one or more stages. It cures the disease and removes all risk of developing cancer in the colon or rectum. However, this operation requires creation of a Brooke ileostomy (bringing the end of the remaining small bowel through the abdominal wall) and chronic use of an appliance on the abdominal wall to collect waste from the bowel.

Some patients may be treated by removal of the colon, with preservation of rectum and anus. The small bowel can then be reconnected to the rectum and continence preserved. This avoids ileostomy, but the risks of ongoing active colitis, increased stool frequency, urgency and cancer in the retained rectum remain.

Are there other surgical alternatives?

The ileoanal procedure is the newest alternative for the management of ulcerative colitis. This procedure removes all of the colon and rectum, but preserves the anal canal. The rectum is replaced with small bowel, which is refashioned to form a small pouch. Sometimes a loop ileostomy is created, but this is closed in several months. Alternatively, you may have a rectal catheter to drain the pouch after the operation, which is then removed in a few days.

The pouch acts as a reservoir to help decrease the stool frequency. This maintains a normal route of defecation, but most patients experience five to ten bowel movements a day. This operation all but eliminates the risk of recurrent ulcerative colitis and allows the patient to have a normal route of evacuation. Patients can develop inflammation of the pouch, which requires antibiotic treatment. In a small percentage of patients, the pouch fails to function properly and may have to be removed. If the pouch is removed, a permanent ileostomy will likely be necessary.

It is important to recognize that none of these alternatives makes a patient with ulcerative colitis normal. Each alternative has perceivable advantages and disadvantages, which must be carefully understood by the patient prior to selecting the alternative, which will allow the patient to pursue the highest quality of life.

It is also important that you meet other patients who have undergone surgical procedures for their ulcerative colitis. This is best done in the local branch of the NACC (National association for Crohns and Colitis) and by talking to our Colorectal specialist nurse who can arrange for you to meet another patient with similar condition.