A client with colitis inquires as to whether surgery eventually will be necessary

Ulcerative Colitis - What it is

Ulcerative Colitis - Symptoms

Ulcerative Colitis - How to prevent?

Ulcerative Colitis - Causes and Risk Factors

Ulcerative Colitis - Diagnosis

Ulcerative Colitis - Treatments

Medication

Initial treatment of ulcerative colitis is medical, using antibiotics and anti-inflammatory medications. Steroids may also be needed. Hospitalization may be necessary to put the bowel to rest.

Surgery

Surgery is needed for life-threatening complications. This include massive bleeding, perforation, or severe infection. It may also be necessary for those who have the chronic form of the disease, where medication fails to work or when the side-effects of medication are intolerable. In addition, patients who have long-standing ulcerative colitis and have a high risk of developing cancer may be offered surgery.

Types of Surgery

Proctocolectomy

Historically, the standard operation for ulcerative colitis has been removal of the entire colon, rectum, and anus. This operation is called a proctocolectomy. It cures the disease and removes all risk of developing cancer in the colon or rectum. However, this operation requires a permanent ileostomy.

Some patients may be treated by removal of the colon, while leaving behind the rectum and anus. The small bowel can then be re-connected to the rectum and patients can pass motion normally. However, there is an increased risk of ongoing disease in the rectum, increased stool frequency, and cancer in the retained rectum.

Ileoanal pouch procedure

The currently preferred operation by colorectal surgeons is an ileoanal pouch procedure. This is the newest alternative. This procedure removes all of the colon and rectum, but preserves the anal canal. The rectum is replaced with small bowel, which is refashioned to form a small pouch. A temporary ileostomy is created while the pouch is allowed to heal, but this is closed in a few months later. The pouch acts as a reservoir to help decrease the stool frequency. This maintains a normal route of defecation, but most patients experience five to ten bowel movements per day. Patients can develop inflammation of the pouch, which requires antibiotic treatment. In a small percentage of patient, the pouch fails to function properly and may have to be removed. If the pouch is removed, a permanent ileostomy will be necessary.

It is important to recognise that none of these alternatives makes a patient with ulcerative colitis normal. Each alternative has perceivable advantages and disadvantages, which must be carefully understood by the patient prior to selecting the operation which will allow the patient to pursue the highest quality of life.

Ulcerative Colitis - Preparing for surgery

Ulcerative Colitis - Post-surgery care

Ulcerative Colitis - Other Information

Crohn’s Disease Complications Requiring Surgery

Medication alone may not adequately control symptoms for everyone with Crohn’s disease. Complications can develop that need more aggressive treatment, including surgery. Seek immediate medical attention if you believe you may have one or more of these complications.

Intestinal obstruction or blockage

Chronic inflammation in the intestines can cause the walls of your digestive organs to thicken or form scar tissue. This can narrow a section of intestine, called a stricture, which may lead to an intestinal blockage. Symptoms of a blockage include crampy abdominal pain, inability to have a bowel movement or pass gas,  nausea and vomiting, and constipation.

Excessive bleeding in the intestine

This is a rare complication of Crohn’s disease. Surgery is performed only if the bleeding cannot be controlled with other treatments.

Perforation of the bowel

Chronic inflammation may weaken the wall of the intestine and cause a hole called a perforation. This can also happen if a portion of the bowel expands and weakens near a stricture.  Once the intestinal wall has been perforated, the contents of the intestine can spill into the abdomen and cause a serious infection called peritonitis.

Fistula

Inflammation can cause sores, or ulcers, to form in the inside wall of the intestines or other organs. Sometimes, these ulcers can extend through the entire thickness of the bowel wall and form a connection or tunnel, called a fistula. Fistulas often occur between two parts of the intestine, between the intestine and another organ such as the bladder or vagina, or break through to the skin surface.

Fistulas can also form around the anal area, which may cause drainage of mucus or stool from an area adjacent to the anus.

Abscess

An abscess, or a collection of pus, can develop in the abdomen, pelvis, or around the anal area. Symptoms include severe pain in the abdomen, fever, painful bowel movements, discharge of pus from the anus, or a lump at the edge of the anus that is swollen, red, and tender. An abscess requires both antibiotics and surgical drainage of the pus cavity.

Toxic megacolon

Severe inflammation in the colon can lead to toxic megacolon. Symptoms include pain, distention/swelling  of the abdomen, fever, rapid heart rate, constipation, and dehydration. This is a potentially life-threatening complication that requires immediate treatment and surgery.

Elective Crohn’s Surgery

Doctors and patients will often consider surgery if a person’s quality of life has been severely impacted despite medical treatment, or if they experience significant side effects from their medication.

Some people find they are no longer responding to their medication. Others decide they are no longer able to cope with severe side effects from their medication.

Colorectal cancer

Patients with Crohn’s disease and ulcerative colitis have a higher risk for colorectal cancer (CRC) than the general population, so elective surgery may be recommended to eliminate that risk.

Colorectal cancer risk factors

• The risk of CRC increases after living with IBD for 8 to 10 years

• The risk increases the longer a person lives with IBD

• The greatest risk is for people with IBD affecting their colon

In most cases, colorectal cancer begins as a polyp, or a small lump growing from the wall of the intestine.  Polyps typically start out benign, or not cancerous, but become cancerous over time. In patients with IBD, abnormal and potentially precancerous tissue, called dysplasia, may lay flat against the wall of the intestine and can even be found in areas of the intestinal wall that appear normal during a colonoscopy.

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Minimizing your Colorectal Cancer Risk - How IBD patients can take control IBD patients can minimize their colorectal cancer risk. Listen to learn more!

Colorectal Cancer Screening

• If you’ve had IBD symptoms for 8 to 10 years or longer, you should have surveillance colonoscopies every one to two years depending on your other risk factors, such as a family history of colorectal cancer.

• A standard colonoscopy is usually accompanied by a series of biopsies, which are small tissue samples taken for microscopic examination.

• If dysplasia is found, even if it’s not cancerous, surgery to remove the colon and rectum is usually recommended to eliminate the risk of developing cancer.

Choosing Your Healthcare Team

If you have been recommended for surgery, you and your doctor should consult with a colorectal surgeon who specializes in surgery of the gastrointestinal tract. Your regular gastroenterologist will continue to treat you before and after your surgery.

• If surgery is elective, take time to research a surgeon and a hospital that fits your needs.

• Your surgeon should be board certified in general surgery or colon and rectal surgery, and should have significant experience performing the surgical procedure that has been recommended for you. Ask your surgeon about his or her experience. Do not be afraid to seek a second or third opinion.

• You can ask your your gastroenterologist or other healthcare provider to recommend surgeons. You can also use our resources to help find a specialist, or check with the American Society of Colon and Rectal Surgeons or the American College of Surgeons for more information.

• Ask your surgeon for help in connecting with other people who have had the same procedure. You can also connect with other patients through the Foundation’s Power of Two program.

• Talk with your surgeon and your other healthcare providers about what preparations you may need before surgery, what to expect after surgery, and any medical supplies you might need once you return home.

• Check to see if your state health departments publish data about the outcomes of certain procedures at specific hospitals.

Thank you to Bonnie & Andrew Stern for supporting the development of educational images and resources on surgery options. Additional support is provided through the Crohn's & Colitis Foundation's annual giving program and donors.