Ulcerative colitis is a long-term condition that is characterized by recurring episodes of inflammation and ulcers that are limited to the mucosal layer of the colon and rectum. The pattern of disease activity is characterized by periods of active inflammation alternating with periods of remission. Although ulcerative colitis is primarily treated medically, surgery is sometimes required as patients can become refractory to medical treatment and develop severe complications.
There are different scores to define the severity of UC and generally it is classified as mild, moderate or severe.
1· Ulcerative proctitis.
2· Left-sided colitis.
Goals of therapy
Mucosal healing is associated with long-term clinical remission, corticosteroid-free clinical remission and avoidance of colectomy. To achieve clinical and endoscopic remission there are several classes of medication including mesalamine, immunomodulators, corticosteroids and biologicals.
Mesalamines are the first-line therapy for induction of remission. Selection among formulations for treatment depends primarily on disease extent.
Second-line therapies for patients with mild-moderate UC who do not respond to mesalamine are corticosteroids. Clinical response usually takes 7-10 days.
Agents currently approved for the induction and maintenance of remission of moderate-severe UC include the biologics infliximab, adalimumab, golimumab, vedolizumab, and ustekinumab, in addition to the small-molecule Janus kinase (JAK) inhibitor tofacitinib.
These patients need to be hospitalized and treatment is based on steroids, infliximab, and cyclosporine. Treatment is based on a multidisciplinary approach by gastroenterology, medicine, and surgery teams, given the risk of significant morbidity and mortality.The immediate goal of therapy is hemodynamic stability and clinical improvement.
The most common elective surgery performed for patients with medically refractory is the restorative proctocolectomy with ileal pouch anal anastomosis.
Indications for emergency surgery:
1· Colonic perforation
2· Massive gastrointestinal hemorrhage
3· Toxic megacolon
4· Acute fulminant colitis