1.Ulcerative colitisBy : Dr. Safia Zahir PGR,S-II

2. Ulcerative Colitis Ulcerative colitis is a chronic inflammatorycondition causing continuous mucosalinflammation of the colon without granulomaon biopsy, affecting the rectum and a variableextent of the colon in continuity, which ischaracterized by a relapsing and remittingcourse. 3. Incidence The incidence of ulcerative colitis in Westerncountries is about 516 new cases per 100,000 peryear with an onset most commonly but notexclusively between 1545 years of age . Theprevalence ranges from 50220 cases per 100,000.Familial, geographic, ethnic and cultural variationshave been identified. (1,2) 4. Disease extent 6 5. 7 6. Mayo score 8 7. Extraintestinal manifestations Arthritis (20%) Ankylosing spondylitis (3-5%) Erythema nodosum (10-15%) Pyoderma gangrenosum (rare) Primary sclerosing cholangitis(5-8%)-Risk of colon CA increased 5xcompared to UC alone 8. UC Diagnosis Rule out infectious causesFecal leukocytes Confirm inflammatory origin to diarrhea, urgencyetcStool cultures, Ova & Parasites Campylobacter, Salmonella, Shigella, C. diff Proctosigmoidoscopy Diffuse, confluent disease from dentate lineproximally Colonoscopy and biopsy is recommended for making diagnosis and determining severity of disease 9. On barium enema, shortened colon in UC, with loss ofhaustrations & destruction of mucosal pattern (lead pipecolon) Ileitis in UC (without the skip pattern) Mucosal surface irregular and friable Rule out Crohns Small bowel follow-through Indeterminate Colitis Treat as UC until/if declares itself Crohns 10. UC Diagnosis On plain radiographyIrregular colon with thumb printing (air in colonic wall)Toxic megacolon :long, continuous segment of air-filled colon greater than 6 cm in diameter (esp. in transverse colon) CT & U/S best for demonstrating mesenteric inflammation,intra-abdominal abscesses and fistulas 11. Specific complications of Ulcerativecolitis.. Toxic megacolon Colonic Perforation Massive hemorrhage Dysplasia and colorectal cancer Stricture 12. Toxic Megacolon Incidence: 5~7% 50% patient present megacolon as their first ulcerative colitisattack Fever, tachycardia, leukocytosis, abdominal distention andtenderness Mortality:15~30%(decline in recent years), usually due todelayed surgery or MODS (3) 13. Toxic megacolon15 14. Perforation Incidence:3~5% with megacolon existence 1% without megacolon Most common at Sigmoid colon Most common cause of death Corticosteroid can mask fatal peritonitis 15. Risk for carcinoma in UC Disease duration 25% at 25 yrs, 35% at 30 yrs, 45% at 35 yrs, and 65% at 40 yrs Pancolonic disease Left-sided only pts less likely to develop cancer than pancolitis pts Continuously active disease Severity of Inflammation Colonic stricture must be considered to be cancer until proven otherwise 16. Risk for carcinoma in UC Colonoscopic surveillance-colonoscopy at 10 years after diagnosis - Followup according to risk stratification - Dysplasia or malignancy on biopsy,proceed to total colectomy 17. Conservative Treatment Anti-inflammatory agents (aminosalicylates, corticosteroids) Immunosupressants Antibiotics TNF (Tumor Necrosis Factor) inhibitors Anti-diarrheal agents Antispasmodic agents Supportive therapy ** 75% of ulcerative colitis patients respond well to medicalmanagement 18. Indications for surgery in UC: SURGICAL EMERGENCIES Massive life threatening hemorrhage(>6 unitsover 24hrs) Toxic megacolon with impending perforation Fulminant colitis unresponsive to IVcorticosteroids Colonic perforation Total obstruction from stricture 19. Timing of emergency surgery -severity of episode/predicated outcome -presence of complications -patients general condition -nutritional status -duration and course of UC -extent of colonic involvement -compliance and complication of drug therapy-patients consent and acceptance 20. Elective: Intractability despite max therapy. Mucosal dysplasia Dysplasia-associated lesion or mass (DALM) Intolerable side effects of medications Patient with significant risk to develop CRC Stricture formation without obstruction 21. Surgical Options 22. Emergency operation: Subtotal colectomy with end ileostomy Proctocolectomy with end ileostomy Blow-hole colostomy with end ileostomy 23. Subtotal colectomy with end ileostomy- long rectal stump is left and is exteriorised as a mucosal fistula -short rectal stump- Advantages : Allows option for IPAA; low risk-Disadvantages : Requires second operation may develop rectal recurrence of disease.- Contraindication : Massive hemorrhage from colon andrectum 24. Proctocolectomy with end ileostomy: Advantages: Definitive treatment Disadvantages : No option for IPAA moderate risk for perineal nerve damage Contraindication : Severely toxic or unstablepatient 25. Blow-hole colostomy with end ileostomy -colonic decompression and proximal diversion using askin level colostomy and loop ileostomy-is rarelyperformed except in pregnant patients, colonic microperforation, high lying splenic flexure, and dense adhesions Advantages: Short, simple decompression procedure Disadvantages : Diseased colon and rectum retained 26. ELECTIVE PROCEDURES Total proctocolectomy with Brooke ileostomy Subtotal colectomy with ileorectal anastomosis Total proctocolectomy with Kock pouch Total colectomy, mucosal proctectomy and hand-sewn IPAA with temporary diverting loop ileostomy(two-stage operation) Total proctocolectomy without mucosectomy andstapled IPAA with temporary diverting loop ileostomy(two-stage operation) Laparoscopic total proctocolectomy with or withoutmucosectomy and IPAA 27. Total proctocolectomy with Brooke ileostomy Indications : Patients wanting to avoid risks of IPAA;elderly; poor sphincter function; rectal cancer Contraindications :Patient aversion to permanentileostomy; obesity; life-threatening emergencies Advantages: Eliminates all disease-bearing mucosa; singleoperation , prevents further inflammation and progressiondysplasia/carcinoma Disadvantages: Potential for nerve injury in the perineal andpelvic dissection; permanent ileostomy; delayed perinealwound healing; mechanical problems with stoma, high riskSBO 28. Subtotal colectomy with ileorectal anastomosis Indications: No rectal involvement; avoid permanentstoma and IPAA; young women of childbearing age topreserve fertility Contraindications : Poor sphincter tone or dysfunction;active rectal or perianal disease; colonic or rectaldysplasia; or frank cancer Advantages: One-stage operation; complete continencewith good function; low risk of pelvic nerve injury;eliminates stoma. Disavantages:30% recurrence rate requiring conversion to ileostomy risk of rectal cancer requiring longlife surveillance 29. Total proctocolectomy with continent ileostomy Introduced by Kock in 1969; popular in the 1970sbecause it offered control of evacuations A single-chambered reservoir is fashioned by suturingseveral limbs of ileum together after the antimesentericborder has been divided The outflow tract is intussuscepted into the reservoir tocreate a valve that provides obstruction to the pouchcontents 30. As the pouch distends, pressure over the valve causes it close andretain stool, permitting patients to wear a simple bandage over askin-level stoma 2-4x/d, the patient introduces a tube through the valve to evacuatethe pouch 31. Total proctocolectomy with Kock pouch Indications : Alternative to conventional ileostomy forpatients desiring to preserve continence; poorsphincter tone; low rectal cancer; failed IPAA;conversion from ileostomy Contraindications : Possibility of Crohns disease;previous resection of small bowel; patients over 60years old; obesity; coexisting medical illness Advantages: Avoids ileostomy; patients remaincontinent; good quality of live; improved body imageover ileostomy Disadvantages: High reoperation rate (35%) due tonipple valve dysfunction or failure; high fistula rate;pouchitis 32. Total proctocolectomy with ileal pouch- anal anastamosis (IPAA or J-pouch) Operative Techniques: Stage I : abdominal colectomy, mucosal proctectomy,endorectal IPAA, and diverting loop ileostomy Stage II : closure of ileostomy Near-total proctocolectomy with preservation of the anal sphinctercomplex A single-chambered pouch is fashioned from the distal 30 cm of theileum and sutured to the anus using a double-stapled technique 33. Total proctocolectomy with ileal pouch-anal anastamosis (IPAA) Alternatively, a hand-sewn anastomosis may be fashioned between the pouch and the anus after stripping the distal rectal mucosa from the internal anal sphincter (mucosectomy) Mucosectomy has been complicated by cancer arising at the anastomosis and extraluminally in the pelvis, evidently from islands of glands that remained after the mucosa was incompletely removed. The mucosectomy technique may conceal retained rectal mucosa in up to 20% of patients Avoiding the mucosectomy preserves the anal transition zone, which contains nerve endings involved in differentiating liquid and solid stool from gas, and is thus thought to provide superior postoperative continence. Temporary fecal diversion (ie diverting loop ileostomy) Recommended in high-risk patients, especially those taking steroids preoperatively 34. Total Proctocolectomy with Ileal PouchAnal Anastomosis Indications : Procedure of choice for ulcerativecolitis; colonic dysplasia or cancer; indeterminatecolitis Contraindications : Poor resting tone or analsphincter dysfunction; low rectal cancers Advantages: Completely restorative;mucosectomy eliminates all disease-bearingmucosa; no disease recurrence; no cancer risk;good function, continence, and quality of life. 35. Disadvantages: Two-stage procedure potential for nerve injury in the perineal and pelvic dissection reduced fertility in females mucosectomy and hand-sewn IPAA are technically demanding and difficult to learn septic complications pouchitis 36. construction of the ileal pouch 37. Post-IPAA: 4 weeks after - barium radiographic study 8 weeks after - anal manometry + clousre ofileostomy 1 3 6 12 month F/U then every year flexible fiberoptic pouchoscopy with surveillancebiopsies of the ileal pouch approximately every 5years. 38. Complications Pouch Failure Pouchitis Crohns Disease dysplasia and carcinoma of the ileal pouch 39. Pouch Failure significant long-term complication of IPAA Prior anal pathology Abnormal anal manometry Pouch-perineal or pouch-vaginal fistulae Pelvic sepsis Anastomotic stricture, and dehiscence Brooke ileostomy or Kock pouch 40. Pouchitis nonspecific, idiopathic inflammation of theileal pouch most common and significant late, long-termcomplication > 50% of ulcerative colitis patients Rare in IPAA for FAP 41. Presentation : stool frequency watery diarrhea fecal urgency Incontinence abdominal cramping fever, and malaise flexible ileal pouchoscopy 42. the greatest risk for experiencing an episodeis during the initial 6-month period followingclosure of the temporary diverting loopileostomy. Risk continues to rise steadily for the next 1836 months before leveling off at around 4years 43. Management : Broad-spectrum antibiotics Acute: Ciprofloxacin 250 mg BID Metronidazole 250 mg QID Chronic: ( treatment for 3 months ) Ciprofloxacin 250 mg OD Metronidazole 250 mg OD topical anti-inflammatory agents, corticosteroids Refractory : undiagnosed Crohns disease ? 44. The Effect of Ageing on Function and Quality of Life in Ileal PouchPatients: A Single Cohort Experience of 409 Patients With ChronicUlcerative Colitis Ann Surg 2004:240(4);615-623 45. References1. 5 Lashner BA. Epidemiology of inflammatory bowel disease.Gastroenterol ClinNorth Am 1995; 24:467742. Corrao G, Tragnone A, Caprilli R, Trallori G, Papi C, AndreoliA, et al. Risk ofinflammatory bowel disease attributable to smoking, oral contraception andbreastfeeding in Italy: a nationwidecase-control study. Cooperative Investigators of theItalian Group for the Study of the Colon and the Rectum(GISC). Int J Epidemiol 1998;27:397404.3. Caprilli R, Latella G, Vernia P, Frieri G. Multiple organ dysfunction in ulcerative colitis.Am J Gastroenterol 2000; 95:125862.4. Andreas M. Kaiser, Robert W. Beart Jr. Surgical management of ulcerativecolitis. SWISS MED WKLY 2 0 0 1 ; 1 3 1 : 3 2 3 3 3 7