Referring Physicians >> Newsletters >> March 2011 IBD Newsletter >> Clinical Scenario: Ulcerative Colitis
A 30-year-old female presents with a 10-year history of ulcerative colitis. Over the course of the last year she has been adversely affected by flaring of her disease activity when maintenance treatment with prednisone drops below 20 mg/day. Her symptoms of increased stool frequency, bleeding, and urgency are consistent with moderate disease activity. Attempts to control her disease activity with other immunomodulating drugs, such as Anti-TNF based therapy, have been unsuccessful.
What tests should be obtained prior to surgical consideration?
The patient should be considered a candidate for surgical management based upon her refractory disease status. Additional management should include a colonoscopy performed within the last year to rule out associated cancer or dysplastic lesions that may impact surgical management.
Hematologic evaluation with a preoperative hemoglobin and hematocrit are essential as they are frequently marginal in the case of prolonged active disease. Along with anemia, nutritional status is another risk factor which can be examined preoperatively. Another consideration in females is history of significant obstetrical trauma that should be addressed prior to colectomy and ileal pouch reconstruction.
The described patient is typical of someone who would be an excellent candidate for minimally invasive proctocolectomy and ileal pouch reconstruction. This is provided the patient does not have a great number of additional risk factors which include obesity, diabetes, cardiovascular problems or profound weight loss and nutritional deficits.
The risks of laparoscopic colectomy include the usual bleeding and infection related problems such as incision infections; although these complications are infrequent with a laparoscopic approach. The patient is also at risk for early onset bowel obstruction or steroid withdrawal related issues which are primarily managed conservatively. In patients that are immune compromised or presenting with significant nutritional deficits, the chances for anastomotic healing problems-such as sinuses-are increased. These may delay eventual ileostomy takedown until complete healing occurs and the patient’s overall health improves.
With no major contraindications to surgery, a laparoscopic colectomy and ileal pouch reconstruction would be the first choice along with a temporary ileostomy. The plans for the transient temporary ileostomy would be a removal in 8-10 weeks, assuming the patient is completely weaned off steroids and has no demonstrable ileal pouch or anastomotic healing problems as confirmed on barium contrast studies. These are typically performed several months after restorative proctocolectomy and prior to eventual ileostomy takedown.
Following the ileostomy takedown the patient is seen as an outpatient and coached on dietary recommendations and methods to optimize ileal pouch function as reflected in a low stool frequency and excellent continence. One sequalae of restorative proctocolectomy for ulcerative colitis has been the past relatively high frequency of pouchitis symptoms. These symptoms present as urgency, increased stool frequency, or bleeding following ileal pouch construction. A major decrease in pouchitis symptoms and development has occurred with the addition of probiotics following ileostomy takedown. In the case of patients that still develop pouchitis, Ciprofloxacin is a first line antibiotic that results in resolution in the vast majority of cases.
Additional factors that can affect functional results:
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