Ulcerative Colitis

What is ulcerative colitis?

Ulcerative colitis is an inflammatory disorder that affects the lining of the large bowel (colon and rectum). The inflammation starts in the rectum and extends for a variable distance in a continuous fashion. It may involve just the rectum (proctitis) or the entire colon (pancolitis). It is uncommon and may present at any age often between 20-50. Occasionally, other organs can be involved including the liver (sclerosing cholangitis), eye (iritis) and skin (pyoderma gangrenosum).

Ulcerative colitis is pre-malignant and can lead to colorectal cancer. The risk of colorectal cancer relates to the severity, amount of colon involved and the duration of inflammation.

What are the symptoms of ulcerative colitis?

The main symptoms are of episodic or continuous diarrhoea with blood and mucous. There may be urgency to defecate, abdominal cramps/pain, weight loss and fevers. The symptoms can range from very mild to severe requiring hospital admission. The disease may have a continuous or a relapsing course and may even “burn-out” after many years.

What is the cause of ulcerative colitis?

The exact cause of ulcerative colitis is not known. There is strong evidence that a combination of factors are probably involved including genetic, immunological, environmental and infectious (bacterial). It is likely that an interaction between these factors leads to IBD in a susceptible individual.

How is ulcerative colitis treated?

Initial treatment of ulcerative colitis is medical management using medications such as salazopyrine or related drugs such as mesalazine. Sometimes anti-inflammatory drugs such as prednisolone or hydrocortisome are required to control the initial presentation or a “flare”. Medications may be given intravenously, orally or sometimes as local rectal preperations depending on the severity and disease location.

Immune suppressants such as azothiaprine and sometimes biologics such as TNF-∝ inhibitors may be required. Colonoscopy to assess the disease and screen for pre-cancerous change (dysplasia) is required.

When is surgery necessary?

Surgery is indicated when medical treatment can no longer control the inflammation or in the setting of pre-cancerous or cancerous change. It may also be required in patients who have a life-threatening complication of ulcerative colitis including massive bleeding, perforation or toxic megacolon.

What operation might I need?

The aim of surgery is to remove the entire colon and rectum. This may need to be done in more than 1 operation particularly in the emergency setting. There are then 2 options. The first is a permanent end ileostomy (see stoma). The second is to construct a “new-rectum” using small bowel (“pouch”). This results in a variable number of loose but controlled bowel motions.

Both of these options all but eliminate the risk of recurrent ulcerative colitis. Patients can develop inflammation in the pouch (pouchitis) which usually responds to antibiotics. In a small number of patients (<20%), the pouch fails to function and needs to be removed, leading to a permanent end ileostomy.

Who should do my surgery?

The decision to operate is always in consultation with both a surgeon and a gastroenterologist. Surgery for ulcerative colitis is challenging and should involve a surgeon who is trained in all aspects of colitis surgery including pouch surgery. In Australia, a colorectal surgeon who has undergone training through the CSSANZ training or alternative international pathway is most appropriate to manage your surgery.

What is a colorectal surgeon?

A colorectal surgeon is an expert in the surgical and non-surgical treatment of colon and rectal conditions. In Australia, a colorectal surgeon has completed general surgical training to be a specialist general surgeon (FRACS). A minimum of 2 years of clinical post-fellowship training is then undertaken in high volume accredited institutions through the Colorectal Surgical Society of Australia and New Zealand (CSSANZ). There is also a research requirement and a written examination on colon and rectal conditions. An equivalent domestic or international experience may qualify a surgeon for CSSANZ accreditation.