Management of the colitis depends on the severity of the attack; children and the elderly present special problems.
Mild to Moderate Attack
Mild or insidious disease usually can be checked with outpatient management. Diet should be free of bovine milk products and any other food that exacerbates diarrhea in the individual patient. In controlled trials, sulfasalazine, 2–6 g/d orally, is effective. Patients who are allergic to sulfonamide drugs can obtain similar benefit with oral mesalamine, 2–5 g/d. Other related drugs include olsalazine (1–3 g/d) and balsalazide. Drug-associated toxicity limits utility in up to 30% of patients treated with these regimens. Ulcerative proctitis and some cases of proctosigmoiditis can be treated with topical mesalamine or steroids. These agents can be delivered by suppository or foam if disease involves only 15–20 cm of distal bowel, and enemas can be used if colitis extends proximally for up to 60 cm; there are several choices of preparations.
Trials have shown that high-dose oral corticosteroids, 100 mg/d cortisone or 40–60 mg/d prednisone, are effective for inducing remission in mild and severe ulcerative colitis. However, low-dose steroids are not effective at maintaining remission. Similar results have been obtained with rectally administered steroids for distal disease.
Severe or fulminating ulcerative colitis requires hospitalization. Nasogastric suction is required in patients with colonic dilation or those at risk of developing this complication. Otherwise, “bowel rest” has no special benefit.
Corticosteroids are given intravenously initially as hydrocortisone (100–300 mg/d) or methylprednisolone (20–80 mg/d). Broad-spectrum antibiotics are often given to severely ill patients in an effort to prevent systemic sepsis from colonic bacterial translocation. Cyclosporine (4 mg/kg/d intravenously) is effective for severe colitis refractory to steroids. Toxicity can be significant, however, and the long-term benefit of cyclosporine treatment is unknown. Hypokalemia is common and should be corrected. Caution should be exercised in administering anticholinergics and opioids because they may precipitate acute dilation of the colon.
Nightly mesalamine suppositories or oral mesalamine serves as maintenance therapy of distal colitis. Immunosuppressive therapy (azathioprine) is used by some physicians to treat ulcerative colitis. Transdermal nicotine reportedly has a therapeutic effect on ulcerative colitis, but clinicians are understandably reluctant to use this agent until more is learned about long-term safety and efficacy.
Surgical Treatment of colitis
Emergency operation is indicated for proved or suspected perforation of the colon. Operation on an urgent basis is required for an acute problem (toxic megacolon, hemorrhage, or fulminating colitis) treated medically at first and then surgically if the response is inadequate. There are no firm guidelines for when to switch from medical to surgical therapy in these cases. If toxic megacolon does not respond to treatment, prompt operation is necessary to avoid perforation. Fulminating disease without megacolon should improve in 4–5 days or less; otherwise, operation may be advisable. Prolonged medical treatment may result in the need for a staged surgical approach, whereas earlier intervention may require only one operation.
Intractable disease is difficult to define. Frequent exacerbations, chronic continuous symptoms, malnutrition, weakness, inability to work, incapacity to enjoy a full social and sexual life—all are elements of intractable disease. Exacerbation of disease when corticosteroids are tapered—and thus inability to discontinue these drugs over months or even years—is a compelling indication for colectomy. Children with chronic colitis may have impaired growth and development. Prevention or treatment of carcinoma is an important indication for operation. Severe extracolonic manifestations, such as arthritis or pyoderma gangrenosum, may respond to colectomy, but other problems (eg, ankylosing spondylitis or sclerosing cholangitis) do not improve after the diseased colon is removed.
Total colectomy with ileoanal anastomosis (restorative proctocolectomy) is the elective operation of choice in most patients. Obesity and advanced age are limiting factors. In this procedure, the entire colon and rectum are excised, and the ileum (made into a reservoir or pouch) is brought into the pelvis and anastomosed to the anal canal just above the dentate line. Rectal mucosectomy was once routine, but many surgeons now do not strip the mucosa at all in patients with colitis; instead, the full thickness of rectum is excised to eliminate disease while preserving good rectal function. A temporary ileostomy to protect the ileoanal anastomosis for 2–3 months is not mandatory, but it is used if there is concern about the patient’s healing properties. Success is expected in 95% of patients.
Proctocolectomy with permanent conventional ileostomy is chosen in patients who may not be candidates for the ileoanal procedure. In an emergency operation, the rectum is preserved to minimize operative complications in an ill patient and to make it possible to do an ileoanal procedure later. This staged operation therefore consists of total abdominal colectomy (subtotal colectomy) and ileostomy with a distal mucous fistula or Hartmann procedure. Ileorectal anastomosis (ileoproctostomy, ileorectostomy) and continent ileostomies are seldom used for ulcerative colitis today.
The mortality rate of ulcerative colitis has dropped sharply in the past 2 decades. First attacks are seldom fatal when treated by specialists. In one large series, emergency colectomy was required in 25% of patients with severe first attacks; 60% responded rapidly to medical therapy; and 15% improved slowly on medications alone. Overall, the colitis-related mortality rate during the year after onset is about 1%. Emergency colectomy has a mortality rate of 6%; most of these deaths are due to perforation, a complication that has a fatal outcome in 40% of cases.
The long-term prognosis of ulcerative proctitis is good; about 10% of patients will develop colonic disease by 10 years, and the mortality rate is very low. If colitis involves the left colon, the prognosis is worse, and in patients with pancolitis, the likelihood of operation during the first year is about 25% and the mortality rate is 5% over 10 years. Colorectal cancer in ulcerative colitis is more often diagnosed at an advanced stage than is sporadic cancer, but the prognosis stage-for-stage is the same. Screening with colonoscopy and biopsies seems to have reduced the cancer mortality rate, but there are still too many patients who escape detection until the malignancy has progressed to incurability. The problem is lack of a sensitive marker that predicts cancer before it develops.
The operative mortality rate is less than 1% for elective colectomy. Quality of life after restorative proctocolectomy with an ileal pouch is excellent. Most patients who undergo the procedure are pleased with the outcome compared with their preoperative symptoms and treatment. In an estimated 90% of survivors, colectomy with ileostomy is consistent with normal life, but a few patients experience problems such as small bowel obstruction and ileostomy dysfunction. Altered sexual function after proctectomy occurs in about 12% of men overall, limited mostly to those over age 50. True impotence is found in 3% of men. Sexual dysfunction is common in the first few months in women.