Patient Information from CSSANZ Website
What is ulcerative colitis?
Ulcerative colitis is a rare disease affecting about 5 per 100,000 of population. Males and females are equally affected and may present at any age, particularly between the second and fourth decades.
What is the cause of ulcerative colitis?
The cause is unknown, but many theories exist. It does not appear to be contagious or hereditary, but rarely more than one family member can have the condition. It is not caused by any dietary factors. It may follow an acute diarrhoeal illness.
How is the bowel affected by ulcerative colitis?
Only the large bowel is involved, with the inflammation starting in the rectum and extending for a variable distance towards the beginning of the large bowel (caecum). If the caecum is involved it is called pancolitis, whereas if the rectum alone is involved it is called proctitis. Ulcerative colitis is comparable to a “bum” of the inner lining of the bowel (mucosa) resulting in inflammation and shallow ulceration which causes diarrhoea, bleeding and mucus. With time the patient may become anaemic, protein and salt depleted.
Can other problems occur with ulcerative colitis?
Occasionally liver disease can occur (sclerosing cholangitis), as can eye inflammation (iritis), arthritis and skin lesions (pyoderma gangrenosum). Ulcerative colitis is also a premalignant disease and the incidence of colon cancer progressively increases with the duration of the disease.
What are the symptoms?
Episodic or continuous diarrhoea with blood and mucus are the main symptoms. There may be urgency to defaecate, with crampy lower abdominal pains. The symptoms can be very mild or so severe that up to 30 bowel actions a day occur. Patients can feel completely normal or become very ill with a life threatening episode.The illness may run a continuous or relapsing course. Occasionally it can “burn out” after a number of years.
How is it diagnosed?
Diagnosis is based on the clinical picture and the appearance of the large bowel mucosa at colonoscopy. Biopsies are taken. In the earliest stages of the disease it is sometimes confused with other conditions. There are no diagnostic blood tests.
When is surgery needed?
Surgery is indicated when medical treatment can no longer control the symptoms that prevent a patient from leading a reasonable lifestyle. Surgery may be indicated in the presence of, or to prevent such complications as haemorrhage, acute toxic colitis and cancer.
What operation might I have?
The aim is to remove all of the large bowel and this can be done in one or more stages. There are two options following total colectomy. The first is to have a permanent ileostomy (bag at the end of the small bowel) and the second is to preserve the anal sphincter muscles to maintain continence, and construct a “new rectum” using small bowel and connecting it to the anus. This removes the need for a permanent ileostomy. This operation, which is called “pouch” surgery or ileoanal reservoir is not suitable for all patients and is more complex surgery than a permanent ileostomy. It results in a variable number of loose but well-controlled bowel actions in a 24 hour period. If cancer has complicated ulcerative colitis the surgical treatment may be modified.
Who should do my surgery?
The decision to operate is always made by the patient’s physician and surgeon in consultation, but it is very important that the surgeon is familiar with all aspects of ulcerative colitis and is skilled in the full range of available surgical techniques. Members of the Colorectal Surgical Society of Australia and New Zealand have these skills, and they are trained in the long term support and follow-up of patients who have had surgery for colitis.
What can I expect after surgery?
Removal of the diseased bowel implies cure without the need for drugs, and removes the risk of cancer. Life expectancy should be normal. With an ileostomy usual occupations and most sports can be resumed. A normal sex life and pregnancy should be possible. Pouch surgery allows defaecation through the anus, however functional results are variable.
What Is Crohn’s Disease?
Crohn’s disease is a type of chronic inflammatory condition that usually involves the small and/or large bowel. The cause is unknown but many theories exist.
Incidence
A rare disease, Crohn’s affects males and females equally at the rate of about 5 per 100,000 of the population. Occasionally more than one family member is affected. Children and adults of any age may suffer from Crohn’s disease, but there are slightly increased peaks of incidence around 25 and 65 years of age. How Does Crohn’s Disease Affect The Bowel The inflammation occurs in a patchy manner and can produce areas of ulceration and narrowing of the small and/or large bowel lining, resulting in localised and general symptoms. Bleeding can lead to anaemia and abscesses can form next to the involved bowel and sometimes burst into other organs causing fistulae (abnormal track). If the anus is involved, fissures, fistulae and watery discharge may be present. The bowel ulceration causes diarrhoea and occasionally malnutrition. Narrowed bowel causes pain and symptoms of intermittent incomplete blockage.
Can Other Organs Be Involved?
Rarely other organs can develop problems such as arthritis, skin conditions and inflammation of the eyes. Some of these conditions respond to medical treatment and others only to surgery.
Symptoms
Abdominal pain, diarrhoea, malaise and fever occur in a chronic manner with acute exacerbations. Bleeding may be present and mixed with the stool, but more often it is not obvious and leads to anaemia and iron deficiency. The abdominal pain may be localised to one point, particularly in the area over the appendix and an incorrect diagnosis of appendicitis is sometimes made. Painful mouth ulcers are common, as is weight loss and tiredness.
Diagnosis
This can sometimes be difficult as Crohn’s disease can mimic many bowel disorders, particularly the irritable bowel syndrome. Large bowel Crohn’s disease (colitis) is best diagnosed by endoscopy (colonoscopy or flexible sigmoidoscopy). Biopsy and barium enema x-rays are sometimes helpful. Small bowel Crohn’s disease requires a small bowel barium x-ray series for diagnosis. Rarely an isotope labelled white cell nuclear scan can identify disease. Certain blood tests may be helpful in the assessment of the severity of the illness. It is sometimes impossible to distinguish between Crohn’s disease and ulcerative colitis.
Treatment
There is no cure for Crohn’s disease. Medication often controls the inflammation, the main drugs being anti-inflammatory, such as Prednisone and Salazopyrine, anti-diarrhoeals and anti-spasmodics, iron and nutritional supplements. Occasionally immune suppressants are used such as Azothiaprine. Where there is a localised complication of Crohn’s disease or an area causing troublesome symptoms that don’t respond to medication the treatment of choice is surgery. The likelihood of surgery being required is high.
What Operation Might I Have?
The surgical procedure is tailored to the specific problem. If short segments of small bowel are involved a widening operation called stricturoplasty is carried out. If a longer length is involved that section of the bowel is removed and the ends rejoined. A stoma of either the large bowel (colostomy) or small bowel (ileostomy) is sometimes necessary and this can be permanent if the anus has been removed; or temporary, if it has been made to allow the residual bowel inflammation to subside. Abscesses always require surgical drainage and occasionally other organs need surgical attention.
Who Should Do My Surgery?
A surgeon who has specifically trained in the management of inflammatory bowel disease who works closely with your physician and who is interested in your wellbeing and quality of life. The members of the Colorectal Surgical Society of Australia have this expertise.
Is More Than One Operation Likely?
About half the patients who require an operation have a second operation at some stage in the future, often years later, and of these another half will require further surgery. Surgery is used to relieve symptoms and complications of Crohn’s disease, and to improve the quality of life.
What About The Future?
Most people with Crohn’s disease lead relatively normal lives, working and raising families, playing sport and enjoy a good life expectancy. Pregnancy is not contra-indicated. Patients with chronic colitis should undergo long term surveillance because of a slight increase in the risk of developing colon cancer. Crohn’s disease can “bum out” after many years but the clinical course of the condition is always unpredictable.
Dr Jennifer Liang 