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Ulcerative colitis rarely affects the anal canal and abscesses and fistulas are uncommon, unlike Crohn’s disease. Although Crohn’s and UC represent separate diseases, about 10% of patients demonstrate features of both conditions making a clear diagnosis difficult. This is known as indeterminate colitis. The exact cause of UC is unclear, it appears to be caused by an exaggerated immune response which attacks the mucosal lining of the colon as if it were foreign tissue. This is probably due to a combination of genetic and environmental factors and some population groups and families are known to have a higher risk for developing UC.


What are the symptoms of UC?

Although the symptoms and severity of UC vary greatly between individuals, common manifestations include; rectal bleeding, passing mucous from the rectum, abdominal pain, diarrhoea, fever and weight loss. Although the majority of patients have chronic ongoing symptoms, some will have severe “flare ups” of UC which require hospital admission and may even necessitate emergency surgery to resolve, this is known as fulminant colitis.

Some patients experience odd symptoms that do not appear to be related to the intestine, (these are known as extra-colonic manifestations) and include joint pain, (arthritis), inflammation of the joints in the spine (ankylosing spondylitis), liver disease (sclerosing cholangitis), eye problems (iritis) and skin lesions. Patients who have longstanding UC have an increased risk of developing colon cancer, the incidence of colon cancer being around 5-10% in those with the disease for 10-20 years and 10-20% in those with the disease between 20-30 years. This risk depends on the extent of the disease and it’s severity and careful screening programs for those with longstanding colitis are recommended (see screening).


How is UC managed?

The mainstay of UC treatment is using drug therapy, this is usually performed by a specialist gastroenterologist. For those with disease limited to the rectum anti-inflammatory or steroid suppositories or enemas such as Mesalazine or Prednisolone may be all that is required. For more extensive disease, other types of medication may be required such as aminosalicylates which selectively deliver an aspirin like compound to the colon.

Steroids are also effective in both the acute phase and to maintain remission but side effects such as osteoporosis, raised blood pressure, diabetes, adrenal suppression and cataract formation have lead gastroenterologists to try to reduce our reliance on them. Immunomodulation therapy with drugs such as azathioprine and methotrexate are used successfully to reduce the patient’s steroid requirements. More recently, medication with antibodies against naturally occurring substances which are involved in the immune response such as infliximab have also shown great benefit in treating disease which would otherwise have required surgery.


When is surgery indicated?

Surgery may be undertaken as an emergency in patients who have a “flare up” of acute colitis which does not respond to medical treatment, often the bowel becomes massively distended and if left may perforate, this is known as a megacolon and surgery should be undertaken before perforation occurs. Some patients develop severe bleeding from the colon which can not be stopped, these patient also require an emergency operation. Other patients have colitis which although not immediately life threatening, is poorly controlled by medicines.

Often the colitis disrupts their life, making them chronically unwell, whilst some have frequent “flare ups” which require repeated hospital admissions and others are dependent upon steroids to control the colitis. These patients should be considered for surgery as should those with long standing UC who develop a cancer in the colon.


What operations are available?

Historically, the standard operation for ulcerative colitis is the proctocolectomy in which the entire colon, rectum and anus are removed and patients have a permanent stoma (ileostomy). In the emergency setting this may be performed in stages with the colon removed first (subtotal colectomy) and an ileostomy formed to allow the patient to recover from their illness and the rectum to be removed at a later stage when the patient has returned to full health and stopped taking any medication.

Although the proctocolectomy is an excellent procedure which cures the disease and removes any risk of developing bowel cancer, it does mean that the patient has a permanent stoma. Most people would prefer not to have a stoma for the rest of their lives and may opt to have a new “rectum” made from loops of small intestine. This is attached to the anal canal so that they can open their bowels without the need of a stoma and is known as an ileoanal (or Park’s) pouch. This procedure is usually performed in 2 or 3 steps, first the colon is removed, the pouch may be fashioned at this time or at a subsequent procedure and a temporary ileostomy formed to allow the pouch to heal.

The stoma is then closed a few months later in a much simpler procedure. The pouch acts as a reservoir to store the faeces prior to defecation. Although bowel function never returns to “normal” and most patients experience five or so bowel movements per day and possibly one at night, satisfaction levels are generally high. In a small number of cases the pouch is not successful and may have to be removed, however this is uncommon. Pouch surgery should not be undertaken lightly and may have an impact on childbearing in young women. You should discuss the suitability of this procedure and other possible complications with a colorectal surgeon experienced in this technique.

Are there any alternatives?

People may hear about the continent ileostomy or Kock pouch. This is like an ileostomy but a pouch of small intestine is created inside the abdomen. The benefit is that there is no need to wear a bag and the reservoir can be emptied by a catheter 3-4 times a day however complication and failure rates for this procedure are high and it is very rarely performed at all nowadays. An alternative procedure has historically been to retain the rectum and join the small bowel directly to it. Although this avoids the need for an ileostomy it does not treat the rectal UC and is not routinely undertaken.


Conclusion

Managing UC can be very complex and should be undertaken by a specialist gastroenterologist in conjunction with an experienced colorectal surgeon.