Ulcerative colitis surgery

Surgical intervention is a potential treatment option in patients with complications such as fistulae or abscesses, or in patients with medically refractory disease. Ulcerative colitis is curable with performance of a total colectomy. Patients with UC may opt to have a colectomy to reduce the chance of developing colorectal cancer. Patients with CD may have affected areas of intestine resected. Unfortunately, CD may recur following surgical resection. Repeated surgeries may lead to significant malabsorption of nutrients and drugs consistent with development of short-bowel syndrome. 

Complications of Crohn s disease may involve the intestinal tract or organs unrelated to it. Small-bowel stricture and subsequent obstruction is a complication that may require surgery. Fistula formation is common and occurs much more frequently than with ulcerative colitis. 

The indications for surgery with Crohn s disease are not as well established as they are for ulcerative colitis, and surgery is usually reserved for the complications of the disease. There is a high recurrence rate of Crohn s disease after surgery. 

Treatments are broadly the same as for ulcerative colitis being based on appropriate supportive measures, and the use of corticosteroids, the cytokine infliximab or adalimumab for severe and complicated disease and immunosuppressants, typically azathio-prine, for reducing the chances of relapse. Full thickness disease leading to flstulation, free perforation, abscess formation and stricturing usually requires surgery. Aminosalicylates appear ineffective in reducing the chances of relapse. 

Therapeutic pyramid approach to inflammatory bowel diseases. Treatment choice is predicated on both the severity of the illness and the responsiveness to therapy. Agents at the bottom of the pyramid are less efficacious but carry a lower risk of serious adverse effects. Drugs may be used alone or in various combinations. Patients with mild disease may be treated with 5-aminosalicylates (with ulcerative colitis or Crohn s colitis), topical corticosteroids (ulcerative colitis), antibiotics (Crohn s colitis or Crohn s perianal disease), or budesonide (Crohn s ileitis). Patients with moderate disease or patients who fail initial therapy for mild disease may be treated with oral corticosteroids to promote disease remission immunomodulators (azathioprine, mercaptopurine, methotrexate) to promote or maintain disease remission or anti-TNF antibodies. Patients with moderate disease who fail other therapies or patients with severe disease may require intravenous corticosteroids, anti-TNF antibodies, or surgery. Natalizumab is reserved for patients with severe Crohn s disease who have failed immunomodulators and TNF antagonists. Cyclosporine is used primarily for patients with severe ulcerative colitis who have failed a course of intravenous corticosteroids. TNF, tumor necrosis factor. 

Ciclosporin may induce remission in some patients with severe ulcerative colitis unresponsive to corticosteroid. The drug is given in a dose of 2-4 mg/kg i.v. until remission is attained. Renal function should be monitored closely as ciclosporin is nephrotoxic (see p. 620). For maintenance therapy azathioprine (see below) is often substituted. Ciclosporin use only delays surgery for many patients after 1 year 50% will have relapsed and undergone colectomy. 

In contrast to ulcerative colitis, about 50% of patients with Crohn s colitis will respond to metronidazole given for up to 3 months, although adverse effects including alcohol intolerance, and peripheral neuropathy from such prolonged therapy often limit its use. The drug is also helpful in controlling perianal and small bowel disease and it decreases the incidence of anastamotic recurrence after surgery. Other antimicrobials, particularly ciprofloxacin may also be effective. 

Although steroids are effective in achieving remission of ulcerative colitis through their anti-inflammatory properties, they do not change the underlying disease process. In comparison with sulfasalazine or other aminosalicylates, corticosteroids seem to have a faster onset of action and induce remission in 2 to 4 weeks. Parenteral corticosteroids are indicated for severe ulcerative colitis. Once a response is achieved, IV corticosteroids should be converted to oral therapy. However, if there is no response from IV corticosteroids within 72 hours, surgery may be indicated. 

Parenteral nutrition is an important component of the treatment of severe Crohn s disease or ulcerative colitis. The use of parenteral nutrition allows complete bowel rest in patients with severe ulcerative cohtis, which may alter the need for proctocolectomy. Parenteral nutrition has also been valuable in Crohn s disease, because remission may be achieved with parenteral nutrition in about 50% of patients. In some patients, the disease may worsen when parenteral nutrition is stopped. Patients with enterocutaneous fistulas of various etiologies benefit from parenteral nutrition. Parenteral nutrition may also be valuable in children or adolescents with growth retardation associated with Crohn s disease, but surgery is often necessary with severe disease. Finally, when possible, home parenteral nutrition should be used for patients requiring long-term therapy, particularly those with short gut as a consequence of surgical resection. 

Hypomagnesemia is usually associated with disorders of the intestinal tract or kidney. Drugs or conditions that interfere with intestinal absorption or increase renal excretion of magnesium can result in hypomagnesemia (Table 50-6). Decreased intestinal absorption as a result of small bowel disease is the most common cause of hypomagnesemia worldwide. These disorders include regional enteritis radiation enteritis ulcerative colitis acute and chronic diarrhea pancreatic insufficiency and other malabsorptive syndromes small-bowel bypass surgery and chronic laxative abuse. ... 

Of 135patients with Crohn s disease (n — 88) or ulcerative colitis (n = 47), 65 stopped taking it because of adverse events after 25 (8-92) days the other 70 patients tolerated mercaptopurine and were followed up for 736 (362-1080) days [109 ]. Mercaptopurine was tolerated in 12 of 17 patients with hepatotoxicity and in 13 of 19 with arthral-gia/myalgia during azathioprine treatment. Previous abdominal surgery was more common in those who had adverse reactions to mercaptopurine (39/65 vs. 27/70), and thiopurine methyltransferase activity was higher in those who were tolerant of mercaptopurine. 

Acute Stage of Ileocolitis or Ulcerative Colitis Mild and Chronic Forms of Colitis Special Dietary Products Drugs and Other Therapeutic Agents Surgery... 

Surgery. Surgical removal of highly inflamed portions of the intestines may be necessary in certain cases of ileocolitis or ulcerative colitis when there is a deterioration due to (1) obstruction of the intestinal opening, (2) bleeding or diarrhea which is difficult to stop, (3) continuous pain, or (4) tumors which may E)ecome cancerous. Fortunately, recent advances in surgical techniques and supportive measures have reduced the risks of such operations. 

Inhibitors of serine proteinase can be used in the therapy of diseases associated with bowels surgery. Under intestinal resection, as well as ulcerative colitis, a high activity of proteolytic enzymes in the faeces are observed, which is highly undesirable (Bohe, 1987). Studies have shown that inhibitors of serine proteinases from potato significantly reduce the depression of the skin in the anogenital region in patients with intestinal resection, as well as healthy children, in which the activity of proteinases in the feces is physiologically increased (Ruseler-van Embden et al., 2004). 

H. Uzun. Vitamin e has a dual effect of anti-inflammatory and antioxidant activities in acetic acid-induced ulcerative colitis in rats. Canadian Journal of Surgery 54(5), 333-338 (2011). 

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