Ulcerative colits ppt


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Ulcerative colits ppt

  1. 1. Ulcerative colitis By : Dr. Safia Zahir PGR,S-II
  2. 2. Ulcerative Colitis• Ulcerative colitis is a chronic inflammatory condition causing continuous mucosal inflammation of the colon without granuloma on biopsy, affecting the rectum and a variable extent of the colon in continuity, which is characterized by a relapsing and remitting course.
  3. 3. Incidence• The incidence of ulcerative colitis in Westerncountries is about 5–16 new cases per 100,000 peryear with an onset most commonly but notexclusively between 15–45 years of age . Theprevalence ranges from 50–220 cases per 100,000.Familial, geographic, ethnic and cultural variationshave been identified. (1,2)
  4. 4. Disease extent 6
  5. 5. 7
  6. 6. Mayo score 8
  7. 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 5x compared to UC alone
  8. 8. UC Diagnosis• Rule out infectious causes Fecal leukocytes • Confirm inflammatory origin to diarrhea, urgency etc Stool 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. 9. • On barium enema, shortened colon in UC, with loss of haustrations & destruction of mucosal pattern (“lead pipe colon”) Ileitis in UC (without the skip pattern) Mucosal surface irregular and friable • Rule out Crohn’s – • Small bowel follow-through• Indeterminate Colitis Treat as UC until/if declares itself Crohn’s
  10. 10. UC Diagnosis• On plain radiography Irregular 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. 11. Specific complications of Ulcerative colitis..• Toxic megacolon• Colonic Perforation• Massive hemorrhage• Dysplasia and colorectal cancer• Stricture
  12. 12. Toxic Megacolon• Incidence: 5~7%• 50% patient present megacolon as their first ulcerative colitis attack• Fever, tachycardia, leukocytosis, abdominal distention and tenderness• Mortality:15~30%(decline in recent years), usually due to delayed surgery or MODS (3)
  13. 13. Toxic megacolon 15
  14. 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. 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. 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. 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 medical management
  18. 18. Indications for surgery in UC:• SURGICAL EMERGENCIES – Massive life threatening hemorrhage(>6 units over 24hrs) – Toxic megacolon with impending perforation – Fulminant colitis unresponsive to IV corticosteroids – Colonic perforation – Total obstruction from stricture
  19. 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. 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. 21. Surgical Options
  22. 22. Emergency operation:– Subtotal colectomy with end ileostomy– Proctocolectomy with end ileostomy– Blow-hole colostomy with end ileostomy
  23. 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 and rectum
  24. 24. • Proctocolectomy with end ileostomy: – Advantages: Definitive treatment – Disadvantages : • No option for IPAA • moderate risk for perineal nerve damage – Contraindication : Severely toxic or unstable patient
  25. 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. 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 and stapled IPAA with temporary diverting loop ileostomy (two-stage operation)– Laparoscopic total proctocolectomy with or without mucosectomy and IPAA
  27. 27. Total proctocolectomy with Brooke ileostomy Indications : Patients wanting to avoid risks of IPAA; elderly; poor sphincter function; rectal cancer Contraindications :Patient aversion to permanent ileostomy; obesity; life-threatening emergencies Advantages: Eliminates all disease-bearing mucosa; single operation , prevents further inflammation and progression dysplasia/carcinoma Disadvantages: Potential for nerve injury in the perineal andpelvic dissection; permanent ileostomy; delayed perinealwound healing; mechanical problems with stoma, high riskSBO
  28. 28. Subtotal colectomy with ileorectal anastomosis – Indications: No rectal involvement; avoid permanent stoma and IPAA; young women of childbearing age to preserve fertility – Contraindications : Poor sphincter tone or dysfunction; active rectal or perianal disease; colonic or rectal dysplasia; or frank cancer – Advantages: One-stage operation; complete continence with 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. 29. Total proctocolectomy with continent ileostomy• Introduced by Kock in 1969; popular in the 1970s because it offered control of evacuations• A single-chambered reservoir is fashioned by suturing several limbs of ileum together after the antimesenteric border has been divided• The outflow tract is intussuscepted into the reservoir to create a valve that provides obstruction to the pouch contents
  30. 30. • As the pouch distends, pressure over the valve causes it close and retain stool, permitting patients to wear a simple bandage over a skin-level stoma• 2-4x/d, the patient introduces a tube through the valve to evacuate the pouch
  31. 31. Total proctocolectomy with Kock pouch– Indications : Alternative to conventional ileostomy for patients desiring to preserve continence; poor sphincter tone; low rectal cancer; failed IPAA; conversion from ileostomy– Contraindications : Possibility of Crohns disease; previous resection of small bowel; patients over 60 years old; obesity; coexisting medical illness– Advantages: Avoids ileostomy; patients remain continent; good quality of live; improved body image over ileostomy– Disadvantages: High reoperation rate (35%) due to nipple valve dysfunction or failure; high fistula rate; pouchitis
  32. 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 sphincter complex• A single-chambered pouch is fashioned from the distal 30 cm of the ileum and sutured to the anus using a double-stapled technique
  33. 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. 34. Total Proctocolectomy with Ileal Pouch–Anal Anastomosis– Indications : Procedure of choice for ulcerative colitis; colonic dysplasia or cancer; indeterminate colitis– Contraindications : Poor resting tone or anal sphincter dysfunction; low rectal cancers– Advantages: Completely restorative; mucosectomy eliminates all disease-bearing mucosa; no disease recurrence; no cancer risk; good function, continence, and quality of life.
  35. 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. 36. • construction of the ileal pouch
  37. 37. • Post-IPAA: – 4 weeks after - barium radiographic study – 8 weeks after - anal manometry + clousre of ileostomy – 1 – 3 – 6 – 12 month F/U then every year – flexible fiberoptic pouchoscopy with surveillance biopsies of the ileal pouch approximately every 5 years.
  38. 38. Complications• Pouch Failure• Pouchitis• Crohns Disease• dysplasia and carcinoma of the ileal pouch
  39. 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. 40. Pouchitis• nonspecific, idiopathic inflammation of the ileal pouch• most common and significant late, long-term complication• > 50% of ulcerative colitis patients• Rare in IPAA for FAP
  41. 41. • Presentation : – stool frequency – watery diarrhea – fecal urgency – Incontinence – abdominal cramping – fever, and malaise• flexible ileal pouchoscopy
  42. 42. • the greatest risk for experiencing an episode is during the initial 6-month period following closure of the temporary diverting loop ileostomy.• Risk continues to rise steadily for the next 18– 36 months before leveling off at around 4 years
  43. 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. 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. 45. References1. 5 Lashner BA. Epidemiology of inflammatory bowel disease.Gastroenterol ClinNorth Am 1995; 24:467–742. 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;27:397–404.3. Caprilli R, Latella G, Vernia P, Frieri G. Multiple organ dysfunction in ulcerative colitis.Am J Gastroenterol 2000; 95:1258–62.4. 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