Ulcerative Colitis

Ulcerative colitis is a dynamic disease characterized by remissions and exacerbations. The

clinical spectrum ranges froman inactive or quiescent phase to low-grade active disease to
fulminant disease. The onset of ulcerative colitis may be insidious, with minimal bloody stools,
or the onset can be abrupt, with severe diarrhea and bleeding, tenesmus, abdominal pain, and
fever. The severity of symptoms depends on the degree and extent of inflammation. Although
anemia iscommon, massive hemorrhage is rare. Physical findings are often nonspecific.

The diagnosis of ulcerative colitis is almost always made endoscopically. Because the rectum
is invariably involved, proctoscopy may be adequate to establish the diagnosis. The earliest
manifestation is mucosal edema, which results in a loss of the normal vascular pattern. In more
advanced disease, characteristic findings include mucosal friability and ulceration. Pus and
mucus may also be present. While mucosal biopsy is often diagnostic in the chronic phase of
ulcerative colitis, biopsy in the acute phase will often reveal only nonspecific inflammation.
Evaluation with colonoscopy or barium enema during an acute flare is contraindicated because
of the risk of perforation.

Barium enema has been used to diagnose chronic ulcerative colitis and to determine the extent
of disease. However, this modality is less sensitive than colonoscopy and may notdetect early
disease. In long-standing ulcerative colitis, the colon is foreshortened and lacks haustral
markings (“lead pipe”colon). Because the inflammation in ulcerative colitis is purelymucosal,
strictures are highly uncommon. Any stricture diagnosed in a patient with ulcerative colitis
must be presumed to be malignant until proven otherwise.

Indications for Surgery.

Indications for surgery in ulcerative colitis may be emergent or elective. Emergency surgery
isrequired for patients with massive life-threatening hemorrhage, toxic megacolon, or
fulminant colitis who fail to respond rapidly to medical therapy. Patients with signs and
symptoms of fulminant colitis should be treated aggressively with bowel rest,hydration, broad-
spectrum antibiotics, and parenteral corticosteroids. Colonoscopy and barium enema are
contraindicated, and antidiarrheal agents should be avoided. Deterioration in clinical condition
or failure to improve within 24 to 48 hours mandates surgery.

Indications for elective surgery include intractabilitydespite maximal medical therapy and
high-risk development of major complications of medical therapy such as aseptic necrosis of
joints secondary to chronic steroid use. Elective surgery also is indicated in patients at
significant risk of developing colorectal carcinoma. The risk of malignancy increases with
pancolonic disease and the duration of symptoms and is approximately 2% after 10 years, 8%
after 20 years, and 18% after 30 years. Unlike sporadic colorectal cancers, carcinoma
developing in the context of ulcerative colitis is more likely to arise from areasof flat dysplasia
and may be difficult to diagnose at an early stage. For this reason, it is recommended that
patients with longstanding ulcerative colitis undergo colonoscopic surveillance with multiple
(40–50), random biopsies to identify dysplasia before invasive malignancy develops. However,
the adequacy of this type of screening is controversial. Recently, magnifying chromoendoscopy
has been used to improve sensitivity.46,47 This technique uses topical dyes that are applied to
the colonic mucosa at the time of endoscopy (Lugol’s solution, methylene blue, indigo carmine,
and others). These dyes highlight contrast between normal and dysplastic epithelium, allowing
more precise biopsy of suspicious areas. Surveillance is recommended annually after 8 years
in patients with pancolitis, and annually after 15 years in patients with left-sided colitis.
Although lowgrade dysplasia was long thought to represent minimal risk, more recent studies
show that invasive cancer may be present in up to 20% of patients with low-grade dysplasia.
For this reason, any patient with dysplasia should be advised to undergo proctocolectomy.
Controversy exists over whether prophylactic proctocolectomy should be recommended for
patients who have had chronic ulcerative colitis for greater than 10 years in the absence of
dysplasia. Proponents of this approach note that surveillance colonoscopy with multiple
biopsies samples only a small fraction of the colonic mucosa, and dysplasia and carcinoma are
often missed. Opponents cite the relatively low risk of progression to carcinoma
(approximately 2.4%) if all biopsies lack dysplasia. Neither approach has been shown
definitively to decrease mortality from colorectal cancer.

Operative Management

Emergent Operation. In a patient with fulminant colitis or toxic megacolon, total abdominal
colectomy with end ileostomy (with or without a mucus fistula), rather than total
proctocolectomy, is recommended. Although the rectum is invariably diseased, most patients
improve dramatically after an abdominal colectomy, and this operation avoids a difficult and
time-consuming pelvic dissection in a critically ill patient. Rarely, a loop ileostomy and
decompressing colostomy may be necessary if the patient is too unstable to withstand
colectomy. Definitive surgery may then be undertaken at a later date once the patient has
recovered. Complex techniques, such as an ileal pouch–anal reconstruction, generally are
contraindicated in the emergent setting. However, massive hemorrhage that includes bleeding
from the rectum may necessitate proctectomy and creation of either a permanent ileostomy or
an ileal pouch–anal anastomosis.

Elective Operation.

Elective resection for ulcerative colitis usually is performed for refractory inflammation and/or
the risk of malignancy (dysplasia). Because of the risk of on going inflammation, the risk of
malignancy, and the availability of restorative proctocolectomy, most surgeons recommend
operations that include resection of the rectum. Total proctocolectomy with end ileostomy has
been the “gold standard” for treating patients with chronic ulcerative colitis. This operation
removes the entire affected intestine and avoids the functional disturbances associated with
ileal pouch–anal reconstruction. Most patients function well physically and psychologically
after this operation. Total proctocolectomy with continent ileostomy (Kock’s pouch) was
developed to improve function and quality of life after total proctocolectomy, but morbidity is
significant, and restorative proctocolectomy is generally preferred today. Since its introduction
in 1980, restorative proctocolectomy with ileal pouch–anal anastomosis has become the
procedure of choice for most patients who require total proctocolectomy but wish to avoid a
permanent ileostomy (see Figs. 29-11 and 29-12).6 Abdominal colectomy with ileorectal
anastomosis may be appropriate for a patient with indeterminate colitis and rectal sparing.