Colon and Small Bowel—Ulcerative Colitis
Concept
Inflammatory bowel disease of unknown etiology. Affects the mucosa of the rectum and colon. Doesn’t have skip areas or full thickness involvement like Crohn’s. Surgery performed for intractable disease or toxic megacolon.
Way Question May be Asked?
“25 y/o male presents to the ED with abdominal pain and bloody diarrhea. Physical exam reveals a temperature of 101, moderate abdominal tenderness, and moderate dis- tension. What do you want to do?” Presentation will usu- ally include some form of diarrhea, abdominal pain, and fever. Rarely arthritis, uveitis, and pyoderma. Make sure to differentiate the patient with ulcerative colitis flare from the patient with toxic megacolon!
How to Answer?
History
Family history
Systemic manifestations (arthritis, uveitis, and pyoderma) Medications (steroids?)
Previous flares
Physical Exam
Vital signs (fever, sepsis) Abdominal exam (peritonitis?)
Rectal exam (will always be involved in UC)
Diagnostic Tests
Full labs Sigmoidoscopy
Abdominal series (colon dilatation, free air) +/− CT scan
Stool for C.diff, O+P, enteric pathogens if unclear etiology
Surgical Treatment
(1) If suspect toxic megacolon
(a) ICU/IVF/transfusion if necessary (b) Antibiotics
(c) NGT/NPO/bowel rest (d) TPN
(e) Steroids (f) Cyclosporine
(g) Serial labs/x-rays/exams
(h) Failure to improve within 48 h or worsening exam→OR for subtotal colectomy and Brooke ileostomy (can bring up mucous fistula to lower portion of wound and not open—will open in
~1/3 pts but less risky than rectal staple line leak)
(i) In unstable pt, can perform Turnbull procedure→ diverting ileostomy and blowhole loop colostomy
(2) If responds to medical treatment, or less acute pres- entation
(a) Barium enema to evaluate extent of disease (b) Colonoscopy and multiple biopsies to evaluate
for dysplasia
(c) UGI with SBFT (r/o Crohn’s) if any doubt (d) Medical treatment with:
azulfidine prednisone steroid enemas 6-MP
lomotil
low residue diet
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(e) Surgery for:
UC unresponsive to medical therapy (uncon- trolled diarrhea, failure to thrive in children) Dysplasia or cancer on colonoscopic biopsy Severe extracolonic disease
(f) Surgical options (choice depends on severity of rectal involvement)
Total proctocolectomy with Brooke ileostomy (if severe)
Total colectomy, anorectal mucosectomy and ileorectal pull through anastomosis (use diverting ileostomy here)
Common Curveballs
Will present as massive bleeding Will not respond to medical treatment Pt will be unstable
There will be free perforation
Pt will have post-op intraabdominal abscess Pt will have leak after ileoanal anastomosis
You’ll be asked your medical regimen for the chronic form of the disease
Scenario will change from toxic megacolon to chronic form of UC
Asked differences between UC and Crohn’s Asked to describe extracolonic manifestations Staple line on Hartmann’s pouch will leak
Pt with perirectal abscess/fistula will have Crohn’s dis- ease—how will you manage?
Strikeouts
Not making the diagnosis of UC
Not ruling out infectious diarrhea or C. diff and taking out the entire colon prematurely
Not performing sigmoidoscopy
Not attempting to treat toxic megacolon with steroids, antibiotics, serial exams but going straight to OR Not differentiating from Crohn’s
Not knowing difference between UC and Crohn’s
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