Surgery for Ulcerative Colitis

Ulcerative colitis is a chronic (long-term) inflammatory disease. It affects the lining of the large intestine, or colon, and rectum. The rectum is the last section of the colon and is located just above the anus. People with ulcerative colitis have tiny ulcers and abscesses in their colon and rectum. These flare up periodically and cause bloody stools and diarrhea. Ulcerative colitis may also cause severe abdominal pain and anemia. Anemia is marked by low levels of healthy red blood cells.

Ulcerative colitis has alternating periods of flare-ups and remission. During remission the disease seems to have disappeared. The periods of remission can last from weeks to years.

The inflammation usually begins in the rectum. It then spreads to other segments of the colon. How much of the colon is affected varies from person to person. If the inflammation is limited to the rectum, the disease is called ulcerative proctitis.

Ulcerative colitis closely resembles Crohn's disease. Crohn's is another inflammatory bowel disease. Often the only thing that distinguishes ulcerative colitis is that it affects only the colon. Crohn's may affect any part of the digestive system, including the mouth. Crohn's disease also is particularly destructive to the small intestine, known as the ileum.

A doctor may order several different types of tests when considering ulcerative colitis as a diagnosis. These include:

• Blood tests
• Stool sample tests
• Imaging tests, such as a CT scan
• Colonoscopy
• Sigmoidoscopy
• Pill camera

About 25% to 40% of people with ulcerative colitis will have to have surgery to remove their colons. The reasons that surgery becomes necessary include:

• Medical treatment -- for instance, drug therapy -- fails to provide results.
• There may be a risk of cancer without surgery.
• The colon has ruptured.
• The patient experiences a severe, sudden onset of the disease.
• There is extensive bleeding.
• Treatment causes side effects severe enough to compromise the patient's health.
• Toxic megacolon has set in. In this dangerous condition, the muscles of the large intestine are dilated, and the colon can rupture.

In some cases, surgery to remove the colon is recommended if other treatments do not work or if the side effects of medications are harming the patient.

Surgery to remove the entire colon is called a colectomy. Surgery to remove both the colon and rectum is a proctocolectomy. Both can be used to treat ulcerative colitis. These surgeries are also performed to eliminate the threat of colon cancer. Colon cancer is common in people with ulcerative colitis. Proctocolectomy is considered the standard treatment when surgery for ulcerative colitis is needed.

If the entire colon is removed, the surgeon may create an opening, or stoma, in the abdominal wall. The tip of the lower small intestine is brought through the stoma. An external bag, or pouch, is attached to the stoma. This is called a permanent ileostomy. Stools pass through this opening and collect in the pouch. The pouch must be worn at all times.

Another procedure is the pelvic pouch or ileal pouch anal anastomosis (IPAA). This is a procedure that does not require a permanent stoma. This surgery is also called a restorative proctocolectomy. The patient is still able to eliminate stool through the anus. In this procedure, the colon and rectum are removed. Then the small intestine is used to form an internal pouch or reservoir -- called a J-pouch -- that will serve as a new rectum. This pouch is connected to the anus. This procedure is frequently done in two operations. In between the operations the patient needs a temporary ileostomy.

The continent ileostomy, or Kock pouch, is an option for people who would like their ileostomy converted to an internal pouch. It's also an option for people who do not qualify for the IPAA procedure. In this procedure, there is a stoma but no bag. The colon and rectum are removed, and an internal reservoir is created from the small intestine. An opening is made in the abdominal wall, and the reservoir is then joined to the skin with a nipple valve. To drain the pouch, the patient inserts a catheter through the valve into the internal reservoir. This procedure, however, is not the preferred surgical treatment for ulcerative patients. That's because of its uncertain results and the potential need for additional surgery.

If the entire colon is removed, ulcerative colitis is cured. This should put an end to the diarrhea, abdominal pains, anemia, and other symptoms.

In addition, the surgical procedures prevent colon cancer. Overall, an estimated 5% of ulcerative colitis patients will develop cancer. The elimination of the colon cancer threat is especially significant for people who have ulcerative colitis that affects the entire colon. In these cases, as opposed to cases of ulcerative colitis that affects only the lower colon and the rectum, the cancer risk without surgery could be up to 32 times the normal rate.

Complications from ileoanal anastomosis may include:

• More frequent and more watery bowel movements
• Inflammation of the pouch (pouchitis)
• Blockage of the intestine (bowel obstruction) from internal scar tissue, called adhesions, caused by surgery
• Pouch failure, which happens in about 8% to 10% of patients with IPAA
• If the pouch fails, the patient will need to have a permanent ileostomy.

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