Ileoanal Pouch Surgery

Ulcerative colitis

Ulcerative colitis is an inflammatory bowel disease (IBD) that causes long-lasting inflammation and ulcers (sores) in your digestive tract. Ulcerative colitis affects the innermost lining of your large intestine (colon) and rectum. Symptoms usually develop over time, rather than suddenly.

Ulcerative colitis can be debilitating and can sometimes lead to life-threatening complications. While it has no known cure, treatment can greatly reduce signs and symptoms of the disease and even bring about long-term remission.

Symptoms

Ulcerative colitis symptoms can vary, depending on the severity of inflammation and where it occurs. Signs and symptoms may include:

  • Diarrhea, often with blood or pus
  • Abdominal pain and cramping
  • Rectal pain
  • Rectal bleeding — passing small amount of blood with stool
  • Urgency to defecate
  • Inability to defecate despite urgency
  • Weight loss
  • Fatigue
  • Fever
  • In children, failure to grow

Most people with ulcerative colitis have mild to moderate symptoms. The course of ulcerative colitis may vary, with some people having long periods of remission.

Types

Doctors often classify ulcerative colitis according to its location. Types of ulcerative colitis include:

  • Ulcerative proctitis. Inflammation is confined to the area closest to the anus (rectum), and rectal bleeding may be the only sign of the disease. This form of ulcerative colitis tends to be the mildest.
  • Proctosigmoiditis. Inflammation involves the rectum and sigmoid colon (lower end of the colon). Signs and symptoms include bloody diarrhea, abdominal cramps and pain, and an inability to move the bowels in spite of the urge to do so (tenesmus).
  • Left-sided colitis. Inflammation extends from the rectum up through the sigmoid and descending colon. Signs and symptoms include bloody diarrhea, abdominal cramping and pain on the left side, and unintended weight loss.
  • Pancolitis. Pancolitis often affects the entire colon and causes bouts of bloody diarrhea that may be severe, abdominal cramps and pain, fatigue, and significant weight loss.
  • Acute severe ulcerative colitis. This rare form of colitis affects the entire colon and causes severe pain, profuse diarrhea, bleeding, fever and inability to eat.

When to see a doctor

See your doctor if you experience a persistent change in your bowel habits or if you have signs and symptoms such as:

  • Abdominal pain
  • Blood in your stool
  • Ongoing diarrhea that doesn't respond to over-the-counter medications
  • Diarrhea that awakens you from sleep
  • An unexplained fever lasting more than a day or two

Although ulcerative colitis usually isn't fatal, it's a serious disease that, in some cases, may cause life-threatening complications.

Causes

The exact cause of ulcerative colitis remains unknown. Previously, diet and stress were suspected, but now doctors know that these factors may aggravate but don't cause ulcerative colitis.

One possible cause is an immune system malfunction. When your immune system tries to fight off an invading virus or bacterium, an abnormal immune response causes the immune system to attack the cells in the digestive tract, too.

Heredity also seems to play a role in that ulcerative colitis is more common in people who have family members with the disease. However, most people with ulcerative colitis don't have this family history.

Risk factors

Ulcerative colitis affects about the same number of women and men. Risk factors may include:

  • Age. Ulcerative colitis usually begins before the age of 30. But, it can occur at any age, and some people may not develop the disease until after age 60.
  • Race or ethnicity. Although whites have the highest risk of the disease, it can occur in any race. If you're of Ashkenazi Jewish descent, your risk is even higher.
  • Family history. You're at higher risk if you have a close relative, such as a parent, sibling or child, with the disease.

Complications

Possible complications of ulcerative colitis include:

  • Severe bleeding
  • A hole in the colon (perforated colon)
  • Severe dehydration
  • Liver disease (rare)
  • Bone loss (osteoporosis)
  • Inflammation of your skin, joints and eyes
  • An increased risk of colon cancer
  • A rapidly swelling colon (toxic megacolon)
  • Increased risk of blood clots in veins and arteries

Diagnosis

Your doctor will likely diagnose ulcerative colitis after ruling out other possible causes for your signs and symptoms. To help confirm a diagnosis of ulcerative colitis, you may have one or more of the following tests and procedures:

  • Blood tests. Your doctor may suggest blood tests to check for anemia — a condition in which there aren't enough red blood cells to carry adequate oxygen to your tissues — or to check for signs of infection.
  • Stool sample. White blood cells in your stool can indicate ulcerative colitis. A stool sample can also help rule out other disorders, such as infections caused by bacteria, viruses and parasites.
  • Colonoscopy. This exam allows your doctor to view your entire colon using a thin, flexible, lighted tube with an attached camera. During the procedure, your doctor can also take small samples of tissue (biopsy) for laboratory analysis. Sometimes a tissue sample can help confirm a diagnosis.
  • Flexible sigmoidoscopy. Your doctor uses a slender, flexible, lighted tube to examine the rectum and sigmoid, the last portion of your colon. If your colon is severely inflamed, your doctor may perform this test instead of a full colonoscopy.
  • X-ray. If you have severe symptoms, your doctor may use a standard X-ray of your abdominal area to rule out serious complications, such as a perforated colon.
  • CT scan. A CT scan of your abdomen or pelvis may be performed if your doctor suspects a complication from ulcerative colitis. A CT scan may also reveal how much of the colon is inflamed.
  • Computerized tomography (CT) enterography and magnetic resonance (MR) enterography. Your doctor may recommend one of these noninvasive tests if he or she wants to exclude any inflammation in the small intestine. These tests are more sensitive for finding inflammation in the bowel than are conventional imaging tests. MR enterography is a radiation-free alternative.

Treatment

Ulcerative colitis treatment usually involves either drug therapy or surgery.

Several categories of drugs may be effective in treating ulcerative colitis. The type you take will depend on the severity of your condition. The drugs that work well for some people may not work for others, so it may take time to find a medication that helps you. In addition, because some drugs have serious side effects, you'll need to weigh the benefits and risks of any treatment.

Anti-inflammatory drugs

Anti-inflammatory drugs are often the first step in the treatment of ulcerative colitis. They include:

  • 5-aminosalicylates. Examples of this type of medication include sulfasalazine (Azulfidine), mesalamine (Asacol HD, Delzicol, others), balsalazide (Colazal) and olsalazine (Dipentum). Which one you take, and whether it is taken by mouth or as an enema or suppository, depends on the area of your colon that's affected.
  • Corticosteroids. These drugs, which include prednisone and hydrocortisone, are generally reserved for moderate to severe ulcerative colitis that doesn't respond to other treatments. Due to the side effects, they are not usually given long term.

Immune system suppressors

These drugs also reduce inflammation, but they do so by suppressing the immune system response that starts the process of inflammation. For some people, a combination of these drugs works better than one drug alone.

Immunosuppressant drugs include:

  • Azathioprine (Azasan, Imuran) and mercaptopurine (Purinethol, Purixan).These are the most widely used immunosuppressants for treatment of inflammatory bowel disease. Taking them requires that you follow up closely with your doctor and have your blood checked regularly to look for side effects, including effects on the liver and pancreas.
  • Cyclosporine (Gengraf, Neoral, Sandimmune). This drug is normally reserved for people who haven't responded well to other medications. Cyclosporine has the potential for serious side effects and is not for long-term use.
  • Infliximab (Remicade), adalimumab (Humira) and golimumab (Simponi). These drugs, called tumor necrosis factor (TNF) inhibitors, or biologics, work by neutralizing a protein produced by your immune system. They are for people with severe ulcerative colitis who don't respond to or can't tolerate other treatments.
  • Vedolizumab (Entyvio). This medication was recently approved for treatment of ulcerative colitis for people who don't respond to or can't tolerate other treatments. It works by blocking inflammatory cells from getting to the site of inflammation.

Other medications

You may need additional medications to manage specific symptoms of ulcerative colitis. Always talk with your doctor before using over-the-counter medications. He or she may recommend one or more of the following.

  • Antibiotics. People with ulcerative colitis who run fevers will likely take antibiotics to help prevent or control infection.
  • Anti-diarrheal medications. For severe diarrhea, loperamide (Imodium) may be effective. Use anti-diarrheal medications with great caution and after talking with your doctor, because they may increase the risk of toxic megacolon (enlarged colon).
  • Pain relievers. For mild pain, your doctor may recommend acetaminophen (Tylenol, others) — but not ibuprofen (Advil, Motrin IB, others), naproxen sodium (Aleve), and diclofenac sodium (Voltaren), which can worsen symptoms and increase the severity of disease.
  • Iron supplements. If you have chronic intestinal bleeding, you may develop iron deficiency anemia and be given iron supplements.

Surgery

Surgery can often eliminate ulcerative colitis. But that usually means removing your entire colon and rectum (proctocolectomy).

In most cases, this involves a procedure called restorative proctocolectomy and ileal pouch anal anastomosis with a temporary diverting ileostomy in the 1st stage. In the 2nd stage the ileostomy is closed to restore the bowel continuity . This procedure eliminates the need to wear a bag to collect stool. Your surgeon constructs a pouch from the end of your small intestine. The pouch is then attached directly to your anus, allowing you to pass stool relatively normally.

Surgery may be needed as an emergency procedure in situation where either the disease cannot be controlled by medications or there is bleeding or there has been a perforation. In such situation a subtotal colectomy with ileostomy is carried out as a 1st stage procedure followed by 2nd stage completion restorative proctocolectomy and ileal pouch anal anastomosis with covering ileostomy. Later on in the 3rd stage the ileostomy is closed to restore the bowel continuity.

In some cases a pouch is not possible. Instead, surgeons create a permanent opening in your abdomen (ileal stoma) through which stool is passed for collection in an attached bag.

Cancer surveillance

You will need more-frequent screening for colon cancer because of your increased risk. The recommended schedule will depend on the location of your disease and how long you have had it.

If your disease involves more than your rectum, you will require a surveillance colonoscopy every one to two years. You will need a surveillance colonoscopy beginning as soon as eight years after diagnosis if the majority of your colon is involved, or 15 years if only the left side of your colon is involved.