Ulcerative colitis (UC) is a chronic inflammatory bowel disease (IBD) that primarily affects the colon and rectum. It is characterized by inflammation and ulceration of the inner lining of the large intestine, leading to symptoms such as diarrhea, abdominal pain, and rectal bleeding. While medical management is the first-line treatment for UC, there are instances where surgery becomes essential for managing the disease and improving the patient’s quality of life. This blog delves into the details of ulcerative colitis and its surgical aspects, providing a comprehensive overview for patients and healthcare professionals.

 

What Is Ulcerative Colitis?

Ulcerative colitis is an autoimmune condition in which the immune system mistakenly attacks the lining of the large intestine, leading to inflammation and ulceration. It typically starts in the rectum and can extend to involve the entire colon (pancolitis). Unlike Crohn’s disease, which can affect any part of the gastrointestinal tract and all layers of the bowel wall, UC is confined to the mucosal layer of the colon and rectum.

 

Symptoms of Ulcerative Colitis

Gastrointestinal Symptoms:

Persistent diarrhea, often with blood or mucus.

Abdominal pain and cramping.

Urgency to pass stools.

Tenesmus (feeling of incomplete evacuation).

 

Systemic Symptoms:

Fatigue and weight loss.

Fever (in severe cases).

Anemia due to chronic blood loss.

Extraintestinal Manifestations:

 

Joint pain (arthritis).

Skin conditions (pyoderma gangrenosum, erythema nodosum).

Eye inflammation (uveitis, episcleritis).

Primary sclerosing cholangitis (PSC), a chronic liver condition.

When Is Surgery Needed in Ulcerative Colitis?

While many patients with UC can be managed with medications such as aminosalicylates, corticosteroids, immunosuppressants, or biologics, approximately 20–30% of patients with UC eventually require surgery.

 

Indications for Surgery

Surgery is considered in the following situations:

 

Failure of Medical Therapy:

Persistent symptoms despite maximum medical therapy.

Dependence on corticosteroids or immunosuppressants to control symptoms.

Severe Complications:

Acute severe colitis: Unresponsive to medical rescue therapy.

Toxic megacolon: A life-threatening condition where the colon becomes severely dilated.

Perforation: A tear in the colon, leading to peritonitis.

Severe bleeding: Uncontrolled hemorrhage from the colon.

Colorectal Cancer or Dysplasia:

Patients with long-standing UC (especially pancolitis for >8–10 years) are at increased risk of developing colorectal cancer.

Dysplasia (precancerous changes) detected on surveillance colonoscopy is an indication for surgery.

Impaired Quality of Life:

Chronic diarrhea, pain, or incontinence that severely impacts daily activities and quality of life.

Types of Surgical Procedures for Ulcerative Colitis

The choice of surgery depends on the patient’s condition, disease severity, and personal preferences. Here are the main surgical options:

1. Total Proctocolectomy with Ileal Pouch-Anal Anastomosis (IPAA)

This is the most common surgery for UC. It involves removing the colon and rectum while preserving the anal sphincter.

A pouch is created from the small intestine (ileum) and connected to the anus, allowing for near-normal defecation.

Advantages:

Cures the colonic disease and eliminates the risk of colorectal cancer.

Avoids the need for a permanent stoma.

Disadvantages:

Risk of complications such as pouchitis (inflammation of the pouch), bowel obstruction, or incontinence.

2. Total Proctocolectomy with Permanent End Ileostomy

The entire colon, rectum, and anus are removed, and a permanent opening (stoma) is created in the abdomen to collect waste in an external pouch.

Advantages:

Definitive cure for UC and eliminates the risk of colorectal cancer.

Avoids the risk of pouch-related complications.

Disadvantages:

Requires lifelong use of an ostomy bag, which may impact body image and quality of life.

3. Subtotal Colectomy with Ileostomy

The majority of the colon is removed, leaving the rectum intact. A temporary ileostomy is created to divert stool.

This is often performed as an emergency procedure for patients with toxic megacolon, perforation, or severe bleeding.

Advantages:

Stabilizes the condition and allows for future reconstructive surgery (e.g., IPAA).

Disadvantages:

Requires a second surgery to remove the rectum or create an ileal pouch.

Post-Surgical Recovery and Life After Surgery

1. Recovery Timeline

Hospital Stay: 5–10 days, depending on the type of surgery and recovery progress.

Return to Normal Activities: Light activities can usually be resumed within 4–6 weeks, but full recovery may take up to 3 months.

2. Dietary Changes

After surgery, patients may need to adjust their diets:

Start with a low-residue diet to allow the digestive system to heal.

Gradually reintroduce high-fiber foods to improve bowel function.

Stay hydrated to compensate for fluid loss, especially if an ileostomy is present.

3. Managing Complications

Pouchitis: This is a common complication after IPAA surgery, characterized by inflammation of the ileal pouch. It is treated with antibiotics and probiotics.

Bowel Obstruction: Adhesions or scar tissue can cause blockages, requiring further treatment.

Stoma Care: Patients with a stoma will need to learn how to care for it and manage an ostomy bag.

Life After Surgery: What to Expect

For most patients, surgery for ulcerative colitis is life-changing and offers a significant improvement in quality of life. Here’s what you can expect:

Improved Symptoms:

Surgery eliminates the diseased colon, resolving symptoms like diarrhea, bleeding, and abdominal pain.

Reduced Cancer Risk:

Removing the colon and rectum eliminates the risk of colorectal cancer, which is a major concern for long-standing UC patients.

Adaptation Challenges:

Patients with a stoma or ileal pouch may need time to adjust to their new anatomy and lifestyle changes.

Support from healthcare providers, stoma care nurses, and support groups can make this transition smoother.

Emotional Well-being:

 

Although surgery is a major decision, most patients report improved emotional and mental health after recovering from the procedure.