Management of acute colitis in inflammatory bowel disease

Colonoscopy of acute colitis. A safe and reliable tool for assessment of severity

Complications that might lead to surgery in severe attacks of ulcerative colitis have been found to be correlated with the depth of colonic ulcerations as measured by pathological examination of colectomy specimens. In order to evaluate the value of colonoscopy for the assessment of colonic ulcerations, we have reviewed the clinical, biological, colonoscopic, and anatomical findings in 85 consecutive patients with attacks of ulcerative colitis involving at least the rectosigmoid and part of the descending colon, seen in our center between 1981 and 1989. All had colonoscopy performed by a senior endoscopist at entry. Extensive deep colonic ulcerations were diagnosed in 46 of them, and moderate endoscopic colitis in 39. No complication related to colonoscopy occurred except for one colonic dilatation. Forty-three of the 46 patients with severe endoscopic colitis were operated upon; 38 of them failed to improve with high-dose corticosteroids and five had a toxic megacolon. Extensive ulcerations reaching at least the circular muscle layer were found at pathological examination of colectomy specimen in 42 of the 43 patients. Conversely, 30 of 39 patients with moderate endoscopic colitis went into clinical remission with medical treatment, and only nine patients needed further surgery because of medical treatment failure. Six of these nine patients underwent another colonoscopy prior to colectomy, and all six showed features of severe endoscopic colitis. Deep ulcerations reaching the circular muscle layer were found at pathological examination in five of these six patients and in one additional patient whose colonoscopy had been performed 21 days before colectomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Management of the rectum following colectomy for acute colitis

During a 6 year period, 31 consecutive patients under the care of one surgeon had emergency colectomies for complicated colitis. A selective policy of closing the rectum intraperitoneally to minimize the length of retained diseased bowel and to avoid a mucus fistula was used during the study period. One patient underwent proctocolectomy, 7 subtotal colectomy with mucus fistula and 23 total colectomies with intraperitoneal closure of the rectum. Two patients (8.9%) developed pelvic sepsis. Both had intraperitoneal closure of the rectal stump and were readily managed by drainage into the stump. Subsequent surgery in the 18 patients having rectal excision has been uncomplicated. Intraperitoneal closure of the rectal stump in emergency surgery for complicated colitis can be performed safely in most of these patients.

Surgical aspects of inflammatory bowel disease

In temperate, developed countries, the principle indications for surgical intervention in inflammatory bowel disease are 1) for the removal of bowel severely damaged by acute or chronic colitis, either Crohn's disease or ulcerative colitis; and 2) for small-bowel Crohn's disease, to overcome the effects of fibrous stenosis and its sequelae, such as abscess or fistula. Unresponsive acute colitis that necessitates emergency surgical intervention involves a total colectomy, end ileostomy, and a mucous fistula of the rectosigmoid above the symphysis pubis. Once the diagnosis is confirmed, a pouch can be considered for patients with ulcerative colitis and an ileorectal anastomosis or proctectomy for those with Crohn's disease. For socially inconvenient colitis (when life with chronic colitis becomes intolerable because of urgency, frequency, or chronic ill health), the patient with ulcerative colitis can be offered proctocolectomy with pouch-to-anus anastomosis as a primary procedure, providing the anal sphincter and pelvic floor function normally. For patients with Crohn's disease, total colectomy and an ileorectal anastomosis can be considered if the rectum is not grossly diseased, and if the anal sphincter has a squeeze pressure of 100 cm and the rectum is capable of holding the balloon distended to 200 ml. It should be noted that better early medical therapy has already led to fewer operations for patients with acute colitis and that safer operations will tend to induce earlier referral for surgery; specifically, safer pouches will induce earlier referrals for patients who have chronic incapacitating diarrhoea. Despite improvement in medical control of the disease, small-bowel Crohn's disease will still tend to be associated with gradual stenosis of the bowel.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical treatment of inflammatory bowel disease--a review of some current opinions and controversies

There are many controversial issues regarding the treatment of patients with inflammatory bowel disease. From this review we have concluded that the longer surgery for Crohn's disease is delayed, the higher the rate is of pre- and postoperative complications. A plea is thus made for relatively early surgical intervention. For Crohn's disease, the general policy today is to perform resections, even if relatively limited ones, rather than to perform by-passes of the macroscopically involved intestine. Indeterminate colitis, as well as self-limiting colitis, are differential diagnoses that the surgeon must be aware of, especially when selecting the appropriate operative method. Due to the existent risk of cancer in ulcerative colitis, some authors advocate prophylactic colectomy after 10 to 15 years, but the most current policy seems to be one of close surveillance, with surgery only in the cases of severe dysplasia or if a so called dysplasia associated lesion or mass (DALM) is diagnosed. Coloproctectomy has been the standard procedure for patients with ulcerative colitis, however, good or even excellent results are often seen after ileorectal anastomosis and pelvic pouch operations. Although all patients cannot benefit from the latter operation it is likely that it will become the principal operation for patients with ulcerative colitis.