Ulcerative Colitis

WHAT IS ULCERATIVE COLITIS?

Ulcerative colitis (UC) is an inflammatory disease affecting the large bowel (colon and rectum). In UC, the inflammation is confined to the internal lining of the intestinal wall (mucosa). Medical management is typically the first option for treatment.  UC can go into remission and recur (come and go).  If surgery is needed for UC, it is usually curative. 

RISK FACTORS

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. 

CAUSES

The exact cause of UC is unknown, but it is not contagious. Potential causes include immune system abnormalities and bacterial infection. 

SYMPTOMS

Most patients develop symptoms in their 30s. A smaller number experience symptoms for the first time later in life (ages 60 to 70). The symptoms of UC are similar to another inflammatory bowel disease, Crohn’s disease. UC, however, only affects the colon and rectum. The most common symptoms of UC include: 

• Abdominal cramping. 

• Pain. 

• Diarrhea. 

• Bleeding with bowel movements. 

• Fever. 

• Fatigue. 

• Weight loss. 

DIAGNOSIS

Ulcerative colitis should be diagnosed by your doctor.  Often, a colonoscopy is performed to diagnose UC.  A colonoscopy looks at the inside of your colon and rectum to find ulcers and inflammation characteristic of UC.  This evaluation helps determine the extent and severity of UC, rules out other diseases such as Crohn’s disease, and guides management. Additional testing may include blood tests, stool samples or imaging such as CT scans or X rays.   

MEDICAL TREATMENT

Medical treatment is the first choice for most patients with ulcerative colitis. The goal of medical therapy is to treat the inflammation and improve a patient's quality of life by decreasing the diarrhea, bleeding, and pain. Long-term medications called immunosuppressants or anti-inflammatory medications are commonly used.   Initially, the most common therapy is corticosteroids but these should only be given briefly because of the side effects. Based on the extent of the disease, medications may be taken by mouth or as a rectal suppository. 

SURGICAL TREATMENT

Surgery is considered for patients when medical management is no longer effective. Other reasons that a patient may require surgery include cancer or pre-cancer is 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). 

UC involves only the colon and rectum and complete removal of both may be curative.  Initially, this would require an ileostomy, or stoma. Some patients may be candidates for an ileal pouch which reconnects the small intestines to the anus. 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 (the muscles that control bowel movements) are located.  The small bowel is then used to create a “new” rectum (the pouch). Because this pouch is often made in the shape of a “J”, it is often called a “J-pouch”. The patient will have a temporary ileostomy during the healing period however ultimately this will be removed and the patient will be able to pass stool through their anus again.    

Planned and emergency surgeries can be performed through traditional “open” procedures or minimally invasive (laparoscopic or robotic) approaches depending on the circumstances. The safest, most effective approach is determined on an individual basis. 

EMERGENCY SURGERY

Because emergency surgery is done for potentially life threatening conditions, it is may need to 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 as an where stool  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. 

ELECTIVE SURGERY

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 loop 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. 

POSTSURGICAL PROGNOSIS

After surgery, five to six bowel movements a day and one at night can be expected, maybe even more. Medications can be used to decrease this. Some patients may experience leakage or incontinence (inability to control bowel movements). Infection or inflammation may develop in the pouch. This can be treated effectively with antibiotics or steroids. Due to complications, about 10% of pouches must be removed and a permanent 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. 

WHAT IS A COLON AND RECTAL SURGEON?

Colon and rectal surgeons are experts in the surgical and non-surgical treatment of diseases of the colon, rectum and anus. They have completed advanced surgical training in the treatment of these diseases as well as full general surgical training. Board certified colon and rectal surgeons complete residencies in general surgery and colon and rectal surgery, and pass intensive examinations conducted by the American Board of Surgery and the American Board of Colon and Rectal Surgery. They are well-versed in the treatment of both benign and malignant diseases of the colon, rectum and anus and are able to perform routine screening examinations and surgically treat conditions if indicated to do so.

DISCLAIMER

The American Society of Colon and Rectal Surgeons is dedicated to ensuring high-quality patient care by advancing the science, prevention and management of disorders and diseases of the colon, rectum and anus. These brochures are inclusive but not prescriptive. Their purpose is to provide information on diseases and processes, rather than dictate a specific form of treatment. They are intended for the use of all practitioners, health care workers and patients who desire information about the management of the conditions addressed. It should be recognized that these brochures should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtain the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances
presented by the individual patient.