Ulcerative colitis is a chronic inflammatory bowel disease that causes continuous inflammation of the colon without granuloma formation. It commonly has an onset between ages 15-45 and is characterized by relapsing and remitting symptoms. Diagnosis involves ruling out infections and confirming inflammatory changes in the colon through endoscopy and biopsy. Treatment focuses on medications to control inflammation, with surgery indicated for complications or treatment failure. Surgical options range from colectomy with ileostomy to total proctocolectomy with ileal pouch-anal anastomosis. Post-surgical complications can include pouchitis, Crohn's disease of the pouch, and dysplasia.

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

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. Incidence
• The incidence of ulcerative colitis in Western
countries is about 5–16 new cases per 100,000 per
year with an onset most commonly but not
exclusively between 15–45 years of age . The
prevalence ranges from 50–220 cases per 100,000.
Familial, geographic, ethnic and cultural variations
have been identified. (1,2)

6. Disease extent
6

7. 7

8. Mayo score
8

9. 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

10. 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 line
proximally
• Colonoscopy and biopsy is recommended for making
diagnosis and determining severity of disease

11. • 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

12. 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

13. Specific complications of Ulcerative
colitis..
• Toxic megacolon
• Colonic Perforation
• Massive hemorrhage
• Dysplasia and colorectal cancer
• Stricture

14. 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)

15. Toxic megacolon
15

16. 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

17. 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

18. 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

19. 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

20. 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

21. • 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

22. • 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

23. Surgical Options

24. Emergency operation:
– Subtotal colectomy with end ileostomy
– Proctocolectomy with end ileostomy
– Blow-hole colostomy with end ileostomy

25.  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

26. • Proctocolectomy with end ileostomy:
– Advantages: Definitive treatment
– Disadvantages :
• No option for IPAA
• moderate risk for perineal nerve damage
– Contraindication : Severely toxic or unstable
patient

27.  Blow-hole colostomy with end ileostomy
-colonic decompression and proximal diversion using a
skin level colostomy and loop ileostomy-is rarely
performed except in pregnant patients, colonic micro
perforation, high lying splenic flexure, and dense adhesions
– Advantages: Short, simple decompression procedure
– Disadvantages : Diseased colon and rectum retained

28. 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

29. 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 and
pelvic dissection; permanent ileostomy; delayed perineal
wound healing; mechanical problems with stoma, high risk
SBO

31. 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

33. 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

34. • 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

35. 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 Crohn's 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

37. 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

38. 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

39. 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.

40. – 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

41. • construction of the ileal pouch

43. • 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.

44. Complications
• Pouch Failure
• Pouchitis
• Crohn's Disease
• dysplasia and carcinoma of the ileal pouch

45. 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

46. 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

47. • Presentation :
– stool frequency
– watery diarrhea
– fecal urgency
– Incontinence
– abdominal cramping
– fever, and malaise
• flexible ileal pouchoscopy

48. • 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

49. • 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 Crohn's disease ?

50. The Effect of Ageing on Function and Quality of Life in Ileal Pouch
Patients: A Single Cohort Experience of 409 Patients With Chronic
Ulcerative Colitis – Ann Surg 2004:240(4);615-623

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