What is ulcerative colitis?
Ulcerative colitis is an inflammatory condition of the large intestine (colon and rectum). Ulcerative colitis and another inflammatory condition known as Crohn’s disease are collectively known as inflammatory bowel disease (IBD).
What are the symptoms of ulcerative colitis?
Symptoms include rectal bleeding, diarrhea, abdominal cramps, weight loss, and fevers. Patients who have had extensive ulcerative colitis for over 8 – 10 years are at an increased risk to develop colorectal cancer.
How is ulcerative colitis diagnosed?
After a thorough evaluation and physical exam your colorectal surgeon or gastroenterologist may recommend a colonoscopy to evaluate the lining of your large intestine. Your physician may ask you about any prior anal fissures, abscess or fistula to exclude Crohn’s disease. At the time of colonoscopy any inflammation seen in the colon and rectum will be biopsied. The location and nature of the inflammation along with your symptom history and pathology results help make the diagnosis of ulcerative colitis.
How is ulcerative colitis treated?
Initial treatment of ulcerative colitis is medical, using antibiotics and anti-inflammatory medications such as aminosalicylates. If your symptoms persist, corticosteroids (prednisone) can be used for a short period of time but long-term use can be associated with significant side effects. Aminosalicylates or immunomodulators (6-mercaptopurine or azathioprine) may be necessary to maintain remission of disease. A stronger class of medications known as biologic agents (infliximab, adalimumab) may be necessary to induce and maintain remission in more severe disease. Hospitalization may be necessary in severe disease to administer intravenous corticosteroids or other medications.
For patients who have ulcerative colitis for over 8 years, colonoscopy with biopsies is recommended every 2 years to exclude dysplasia (pre-cancer) or cancer.
What does surgery involve?
Ileal pouch-anal anastomosis (IPAA) is the most common surgical procedure for the management of ulcerative colitis. The procedure involves removal of the entire colon and rectum, but preserves the anal canal. The small intestine (terminal ileum) is fashioned to make a pouch that looks like a “J” (J-pouch), which is connected to the anus. A temporary ileostomy is created to divert the stool from the J-pouch and allow it to heal. The ileostomy is usually reversed in 2 months.
The procedure may be performed in 2 or 3 stages or operations depending on your overall health and nutrition at the time of surgery. When surgery is performed on an emergency basis or when medications (steroids) have made your tissues too friable or resulted in too much fat tissue in the mesentery (blood vessels to the colon), the procedure may be performed in 3 stages rather than 2 stages. During the first operation, the colon is removed, but the rectum is left in place and an ileostomy is created. This allows the patient to heal and come off of the medications and get stronger. During the next operation generally performed 3 months later, the rectum is removed, the small intestine is used to create the J-pouch and another ileostomy is created to allow the J-pouch to heal. During the last stage (2 months after the J-pouch) the ileostomy is reversed.
What can I expect after IPAA?
Although the procedure is major abdominal surgery, most individuals start feeling better quickly. The sense of urgency is almost always resolved immediately. At first, patients will have multiple bowel movements a day, but will have the control to make it to the toilet. Over several months, as the J-pouch begins to function more like a rectum, the number of bowel movements will decrease down to 4-6 movements.
The most common early complications after J-pouch surgery are related to the ileostomy, where patients can become very dehydrated due to the watery output.
Patients can develop inflammation of the pouch (pouchitis) after J-pouch surgery, which usually responds to antibiotic treatment. In a small percentage of patients, severe inflammation of the pouch can develop and the pouch fails to function properly and may have to be revised or removed. If the pouch is removed, a permanent ileostomy will likely be necessary.
The idea of having such a major operation may be daunting for many patients. For a thorough evaluation, treatment recommendations and to discuss the technical aspects of surgery for ulcerative colitis, call to make an appointment for a consultation with Dr. Zaghiyan in her office in Los Angeles.