Surgical Options for Acute Ulcerative Colitis

Surgical Options for Acute Ulcerative Colitis

Mortensen Neil , Singh Baljit
European Gastroenterology & Hepatology Review - Volume 4 - Issue I
Published: January 2009
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There are a number of causes of colitis, the most frequent being inflammatory bowel disease, which comprises ulcerative colitis (UC) and Crohn’s disease (CD). In the acute setting the management of colitis is often confined to that of UC, but other causes of acute colitis should not be overlooked, including bacterial, viral, parasitic, ischaemic and drug-induced. The surgical management of acute colitis cannot be described in isolation, but goes hand in hand with the medical management of this condition. The acute presentation of bloody diarrhoea should initiate routine blood tests, stool culture, plain radiographs and a rigid sigmoidoscopy. The severity of an acute attack of UC can be determined by the Truelove and Witts classification.1 Stool culture should be examined to exclude bacterial or parasitic causes. It is also important to test stool for Clostridium difficile toxin to exclude pseudomembranous colitis.

A sigmoidoscopy is useful as it will reveal rectal inflammation. Furthermore, a biopsy will be able to exclude cytomegalovirus (CMV) infection. This is important as successful medical management of CMV colitis obviates the need for surgery. The findings of a toxic megacolon or mucosal islands on an abdominal X-ray are indicative in three-quarters of patients of the potential failure of medical management and the likelihood of requiring surgery.2 Travis et al. have described predictors for surgery,3 and they noted that a stool frequency greater than or equal to eight movements a day or a C-reactive protein greater than 45mg/l on day three during admission is associated with an 85% chance of requiring surgery.

The mainstay of medical treatment has been intravenous steroids. However, approximately 60% of patients have been reported to be resistant to this therapy. The alternative possibilities, which are referred to as second-line treatment, include the use of ciclosporin or a monoclonal antibody to tumour necrosis factor-alpha (infliximab). The former can be used as an intravenous or oral preparation. Additionally, ciclosporin does not increase the risk of peri-operative complications.4 However, while ciclosporin is effective in the treatment of acute severe UC, infliximab has been shown to be effective only for moderate UC.5,6 In addition, the longer half-life of infliximab compared with ciclosporin – days compared with hours, respectively – can potentially render a patient immunosuppressed following surgery. In theory, this can lead to increased post-operative morbidity, especially infective complications.

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