Ulcerative Colitis Complications Toxic Mega Colon: Surgery Options

Posted on September 8, 2009 by mkr in Digestive Disorders

The complications of ulcerative colitis are numerous. These can be divided into two main groups

  1. Local complications.
  2. Systemic or remote complications.

Local complications

  1. Hemorrhage.
  2. Perforation of rectum either producing peritonitis or confined with abscess or fistula formation.
  3. Stricture formation with partial obstruction.
  4. Peri-anal (around anus) and peri-rectal abscesses and fistulas.
  5. Toxic mega-colon.
  6. Carcinoma of the colon.

Of these, two complications- toxic mega-colon and carcinoma of colon are very common.

Toxic Mega-colon

  • It is a manifestation of fulminant colitis and usually occurs with the initial acute episode, less frequently during a relapse of the remitting type of ulcerative colitis.
  • The cause of toxic dilatation is not known.
    Necrotizing inflammation of the smooth muscles of the bowel due to deep ulcers and at times damage to the small plexus of blood vessels seems to be the main cause.
  • Other factors which may play main role in this condition are hypocalcaemia, hypoprotinaemia, anti-cholinergic drugs etc.

Carcinoma Of Colon

  • This is a late complication of ulcerative colitis particularly of chronic and continuous form of the disease.
  • Incidence of carcinoma in ulcerative colitis is about 10 to 30 times more than in general population.

Systemic complications include

  1. Macrocytic anemia.
  2. Hypoprotinaemia.
  3. Avitaminosis.
  4. Amenorrhea.
  5. Osteoporosis.
  6. Retarded sexual development and retarded growths.

This disease produces complications in certain specific organs such as:

  1. Eyes- conjunctivitis, iritis, choroids inflammation etc.
  2. Joints- arthralgia (swelling, pain, redness of joint with migratory involvement) mainly affecting lower limb joints.
  3. Bones- different types of inflammatory disease.
  4. Skin- erythematic nodes, clubbing of fingers, apthous stomatitis etc.
  5. Liver and gallbladder- fatty liver, hepatitis, cirrhosis, gallstones, carcinoma of the bile duct.
  6. Urinary system- inflammation of the kidney urolithiasis.
  7. Interstitial pancreatitis.
  8. Peripheral neuropathy.
  9. Vascular thrombosis.

Ulcerative Colitis Surgery Options

75 to 80% of patients with ulcerative colitis are satisfactorily managed by medical treatment. Only 10% require surgery.

Indication for emergency surgery are:

  1. Massive and unrelenting hemorrhage.
  2. Toxic mega-colon with impending perforation.
  3. Fulminating acute ulcerative colitis which is not responding to medical treatment.

Indication for elective surgery are:

  1. Partial intestinal obstruction.
  2. Confined perforation with abscess formation.
  3. Chronic disease not responding to medical treatment.
  4. Rectal complications such as abscess and fistulae, serious systemic or distant complications not responding to medical treatment.
  5. Long continued colitis which carries higher risk of colonic cancer.

Proctocolectomy

  • Main surgery is single staged total procto-colectomy (resection of the rectum).
  • This procedure is performed through midline incision. After the abdomen has been opened, a full exploration is made with particular attention to the state of the liver and of the biliary tract, as gallbladder stones are common.

Ileostomy

  • Sometimes ileostomy alone may be performed in gravely ill patients, who are not suitable for total colectomy.

Total procto-colectomy with ileo-anal pouch

  • In this operation two loops of terminal ileum are sutured side by side to form a pouch before anastomosing with anal canal. This pouch substitutes the rectum for normal defecation. This pouch may need to be irrigated by the patient to achieve evacuation. This technique is done at a few colo-proctological centers.

Post-operative Complications

Besides usual complications, which may follow major abdominal operations such as pulmonary collapse, infection, wound abscess, deep-vein thrombosis, pulmonary embolism hemorrhage etc., certain specific complications may follow this operation and these include

  1. Infection- a gram negative septicemia may follow this operation.
  2. Paralytic ileus (paralysis of intestine), is treated by conservative treatment.
  3. Intestinal obstruction.
  4. A persistent perineal sinus.
  5. Ileostomy prolapse.
  6. Skin problems.

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