Hepatobiliary disease associated with ulcerative colitis

A comprehensive review of inflammatory bowel disease focusing on surgical management

The two main diseases of inflammatory bowel disease are Crohn's disease and ulcerative colitis. The pathogenesis of inflammatory disease is that abnormal intestinal inflammations occur in genetically susceptible individuals according to various environmental factors. The consequent process results in inflammatory bowel disease. Medical treatment consists of the induction of remission in the acute phase of the disease and the maintenance of remission. Patients with Crohn's disease finally need surgical treatment in 70% of the cases. The main surgical options for Crohn's disease are divided into two surgical procedures. The first is strictureplasty, which can prevent short bowel syndrome. The second is resection of the involved intestinal segment. Simultaneous medico-surgical treatment can be a good treatment strategy. Ulcerative colitis is a diffuse nonspecific inflammatory disease that involves the colon and the rectum. Patients with ulcerative colitis need surgical treatment in 30% of the cases despite proper medical treatment. The reasons for surgical treatment are various, from life-threatening complications to growth retardation. The total proctocolectomy (TPC) with an ileal pouch anal anastomosis (IPAA) is the most common procedure for the surgical treatment of ulcerative colitis. Medical treatment for ulcerative colitis after a TPC with an IPAA is usually not necessary.

Surgical management of inflammatory bowel disease

Indications for operation in patients with inflammatory bowel disease are now standardized as a result of the vast surgicaL experience that has been accumulated during the past 40 years. The surgical indications in Crohn's disease and chronic ulcerative colitis vary minimally with the anatomic distribution of either disease, and can be recognized easily in a particular patient. Consequently, decision or judgment regarding the need for operation is rarely difficult. Delaying operation on the basis of fear of recurrence of Crohn's disease is unrealistic because (1) indications for operation are complications of the disease that have not responded or cannot be expected to respond to medical treatment, (2) conservative resection primarily removes diseased bowel that will never return to normal, (3) many patients, perhaps 50%, will never have recurrence of disease, and (4) those who have recurrence will have experienced varying periods when they were free of disease and relieved of the serious complications for which their operations were performed. The value of surgery in the treatment of patients with chronic ulcerative colitis can be stated even more positively, because recurrence of disease is never a concern after proctocolectomy.

Portal vein bile acids in patients with severe inflammatory bowel disease

The incidence of several forms of liver disease associated with inflammatory bowel disease has been putatively ascribed to a toxic effect on the liver of portal vein bile acids abnormal in type or amount. To examine this possibility, total bile acid concentrations (sulphated and non-sulphated) were measured by gas-liquid chromatography in inferior mesentric vein serum of 19 patients undergoing colectomy for severe inflammatory bowel disease (IBD). Similar determinations were obtained on a control group of eight patients requiring colectomy for other non-inflammatory conditions. Mean values for mesenteric vein serum bile acid concentrations (muM/1) were 19.6+/-1.8 in controls and 16.3+/-2.0 in IBD. The mean sulphated bile acid fraction did not exceed 10% of total, although there was considerable variability (up to 40% of total). Lithocholic acid levels (entirely sulphated in all patients) were low. Although the IBD group showed a more than two-fold increase in mean lithocholate concentration (0.54+/-0.15 muM/1) over controls (0.21 +/- muM/1), this difference was not statistically significant. No significant intra-group difference was noted in the non-sulphated and sulphated fractions for cholic, chenodeoxycholic, and deoxycholic acid species, respectively. No unidentified or unusual bile acids were observed. There was no correlation between bile acid measurements and liver histology. These findings fail to support the hypothesis that liver disease often found in association with severe inflammatory bowel disease represents a form of bile acid toxicity. The invariable finding of total sulphation of the lithocholic acid fraction even in the presence of severe mucosal disease was unexpected.