Special Surgery 21. Surgical Aspects of Ulcerative Colitis

I. Ulcerative Colitis Overview Relevant to Surgery

Definition and Morphology

• Ulcerative colitis: chronic inflammatory bowel disease affecting only colon and rectum
• Location: colon + rectum → rectum is always involved in classic UC
• Pattern: continuous lesion from rectum proximally; no skip lesions
• Depth: mucosal and submucosal inflammation, not transmural like Crohn disease
• Microscopy: cryptitis, crypt abscesses, chronic mucosal architectural distortion
• Surgery can be curative because the diseased organ is removed

Clinical Features

1. Intestinal Manifestations

• Onset: often teenage / young adult
• Bloody diarrhea with mucus
• Tenesmus and urgency
• Abdominal pain: usually LLQ
• Weight loss, fever, fatigue in active/severe disease

2. Extraintestinal Manifestations

• Joints: arthritis, ankylosing spondylitis, sacroiliitis
• Skin: erythema nodosum, pyoderma gangrenosum
• Eyes: uveitis, episcleritis
• Hepatobiliary: primary sclerosing cholangitis (PSC), more common association than in Crohn disease
• Perianal fistula/abscess/fissure: not typical UC → suspect Crohn disease or another diagnosis if prominent

Complications

• Toxic megacolon: toxic colonic dilation due to severe inflammation and deeper-wall paralysis
• Fulminant colitis: severe sudden flare → dehydration, systemic toxicity, sepsis risk
• Perforation: often related to toxic megacolon → peritonitis
• Severe bleeding, rarely massive lower GI bleeding
• Increased colorectal cancer risk, especially long-standing pancolitis and PSC

Diagnosis

• Labs: increased CRP/ESR/WBC, iron-deficiency anemia, low albumin in severe disease
• Fecal calprotectin: increased intestinal inflammation marker
• Stool tests: exclude infection, especially C. difficile in severe flare
• Colonoscopy: ulceration, erythema/friability, loss of vascular pattern, continuous inflammation
• Biopsy: mucosal/submucosal inflammation, crypt abscesses, chronic architectural distortion
• Acute severe colitis: careful flexible sigmoidoscopy; avoid full colonoscopy because perforation risk

Medical Treatment Overview

1. Induction

• 5-ASA / mesalazine: mild-moderate disease
• Corticosteroids: prednisolone or budesonide for flare induction, not long-term maintenance
• Immunomodulator: azathioprine, mainly steroid-sparing maintenance role
• Biologics: anti-TNF (infliximab, adalimumab), vedolizumab, ustekinumab
• Small molecules: JAK inhibitors such as tofacitinib or upadacitinib in selected patients

2. Maintenance

• Mesalazine, immunomodulators, biologics or small molecules according to severity and response
• Surgery if emergency complication, cancer/dysplasia risk, or medical therapy fails

II. Surgical Indications

Emergency / Urgent Indications

• Toxic megacolon:

• Severe colonic dilation + systemic toxicity
• High perforation risk → surgery if unresponsive to intensive medical treatment

• Perforation: life-threatening → urgent colectomy
• Acute severe / fulminant colitis unresponsive to maximal medical therapy:

• No improvement after about 48-72 h of IV steroids +/- rescue biologic/cyclosporine assessment
• Early surgical consultation; avoid prolonged failed medical therapy

• Massive lower GI bleeding: rare, but urgent colectomy if uncontrolled

Elective Indications

• Medically refractory disease: persistent symptoms despite optimized therapy
• Steroid dependence or severe steroid toxicity
• Dysplasia or colorectal cancer
• Long-standing high-risk disease, especially pancolitis after 8-10 years or PSC, if surveillance finds high-risk lesions
• Growth failure or delayed puberty in children
• Medication intolerance, contraindication, or unacceptable quality-of-life burden

III. Surgical Options

Emergency Operation: Subtotal Colectomy with End Ileostomy

• Temporizing standard operation in emergency severe UC
• Removes colon, creates end ileostomy, leaves rectal stump or mucous fistula
• Used for toxic megacolon, perforation, acute severe refractory colitis, severe bleeding
• Reason: patient may be septic, malnourished, anemic, steroid-exposed → immediate pouch is unsafe
• Later option: completion proctectomy + IPAA or permanent end ileostomy
• Retained rectum needs surveillance if left long-term

Total Proctocolectomy with Ileal Pouch-Anal Anastomosis (IPAA)

• Most common restorative curative procedure for suitable UC patients
• Removes entire colon and rectum, preserves anal sphincter
• Terminal ileum is folded into a pouch, usually J-pouch → anastomosed to anal canal
• Usually performed in 2 or 3 stages, especially after acute severe disease

Typical 3-Stage Pathway

1. Subtotal colectomy + end ileostomy
2. Completion proctectomy + IPAA + diverting loop ileostomy
3. Ileostomy closure

Total Proctocolectomy with Permanent End Ileostomy

• Definitive and curative, but no pouch is created
• Preferred if weak sphincter, fecal incontinence, high operative risk, older/frail patient, low rectal cancer/sphincter problem, suspected Crohn disease, or patient preference
• Requires lifelong stoma care education and support

Operation Choice

• UC surgery principle: curative colectomy/proctectomy while preserving continence and quality of life when possible
• IPAA vs permanent ileostomy depends on patient age, comorbidities, sphincter function, cancer situation, diagnosis certainty and preference
• Confirm diagnosis before pouch: Crohn disease or prominent perianal fistulizing disease increases pouch failure risk

IV. Postoperative Considerations and Complications

IPAA / J-Pouch Complications

• Pouchitis: common → increased stool frequency, urgency, cramps, pelvic discomfort; usually treated with antibiotics
• Anastomotic leak and pelvic sepsis
• Small bowel obstruction / ileus
• Incontinence, urgency or frequent bowel movements
• Fertility issues in women after pelvic surgery
• Pouch failure: refractory sepsis, poor function, Crohn-like pouch disease or severe chronic pouchitis → diversion or pouch excision may be needed

Stoma and Rectal Stump Considerations

• Permanent ileostomy: patient education, appliance fitting, skin care, dehydration/high-output risk recognition
• Temporary ileostomy: closure after pouch/anastomosis has healed and patient recovered
• Rectal stump after subtotal colectomy: can bleed, inflame, perforate rarely, and needs cancer surveillance if retained

Cancer Surveillance After Surgery

• Complete proctocolectomy removes colorectal mucosa and therefore removes ordinary UC-related CRC risk
• Retained rectal stump: continued endoscopic surveillance is required
• IPAA: pouch/rectal cuff surveillance in high-risk patients, especially previous dysplasia/cancer or PSC