What is ulcerative colitis?
Ulcerative
colitis is an inflammation of the lining of the large bowel
(colon). Symptoms include rectal bleeding, diarrhea, abdominal
cramps, weight loss, and fevers. In addition, patients who
have had extensive ulcerative colitis for many years are
at an increased risk to develop 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 Alzulfidine, Prednisone, etc.). These are usually necessary
on a long-term basis. Prednisone 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.
Hospitalization 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 medical therapy. It is important the patient be comfortable
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 (Illustration
A) 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
bowel through the abdomen wall, Illustration B) and
chronic use of an appliance on the abdominal wall to collect
waste from the bowel.
The continent ileostomy (Illustration C) is similar
to a Brooke ileostomy, but an internal reservoir is created.
The bowel still comes through the abdominal wall, but an
external appliance is not required. The internal reservoir
is drained three to four times a day by inserting a tube
into the reservoir. This option eliminates the risks of
cancer and risks of recurrent persistent colitis, but the
internal reservoir may begin to leak and require another
surgical procedure to revise the reservoir.
Some
patients may be treated by removal of the colon, with preservation
of the rectum and anus. The small bowel can then be reconnected
to the rectum and continence preserved. This avoids an 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. Usually, a temporary ileostomy is
created, but this is closed in several months. 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 per 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.
Which alternative is preferred?
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.
