Coloproctology pp 157-176 | Cite as

Inflammatory Bowel Disease: Ulcerative Colitis

  • P. J. ConaghanEmail author
  • N. J. Mc C. Mortensen
Part of the European Manual of Medicine book series (EUROMANUAL)


Ulcerative colitis is a chronic, relapsing idiopathic inflammation of the rectum and variable lengths of the adjoining colon. Onset usually occurs during the third and fourth decades of life and commonly presents with bloody diarrhea. A diagnosis is made using a combination of endoscopic and histological evidence to distinguish it from other inflammatory colitides, in particular Crohn’s disease. The extent of the disease in terms of the amount of colon involved and the severity of the attacks both vary, and treatment is tailored depending on both these factors. Ulcerative colitis predisposes individuals to colorectal cancer, and surveillance is required for most sufferers. Acute severe colitis is the most serious manifestation of the disease and initially requires hospital treatment with intravenous steroids. Emergency surgery in the form of a subtotal colectomy and end ileostomy is vital in those not responding to medical treatment to avoid colonic perforation. There are two major elective procedures: restorative proctocolectomy (ileoanal pouch procedure) and panproctocolectomy. Laparoscopic surgery is now an option for both emergency and elective procedures.


Ulcerative colitis Inflammatory bowel disease Diarrhea Colorectal cancer Proctocolectomy Ileoanal pouch Laparoscopic surgery 


  1. 1.
    Loftus Jr EV. Clinical epidemiology of inflammatory bowel disease: incidence, prevalence, and environmental influences. Gastroenterology. 2004;126(6):1504–17.CrossRefPubMedGoogle Scholar
  2. 2.
    Shivananda S, Lennard-Jones J, Logan R, Fear N, Price A, Carpenter L, et al. Incidence of inflammatory bowel disease across Europe: is there a difference between north and south? Results of the European Collaborative Study on Inflammatory Bowel Disease (EC-IBD). Gut. 1996;39(5):690–7.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Ardizzone S, Bianchi Porro G. Inflammatory bowel disease: new insights into pathogenesis and treatment. J Intern Med. 2002;252(6):475–96.CrossRefPubMedGoogle Scholar
  4. 4.
    Birrenbach T, Bocker U. Inflammatory bowel disease and smoking: a review of epidemiology, pathophysiology, and therapeutic implications. Inflamm Bowel Dis. 2004;10(6):848–59.CrossRefPubMedGoogle Scholar
  5. 5.
    Andersson RE, Olaison G, Tysk C, Ekbom A. Appendectomy and protection against ulcerative colitis. N Engl J Med. 2001;344(11):808–14.CrossRefPubMedGoogle Scholar
  6. 6.
    Spehlmann ME, Begun AZ, Burghardt J, Lepage P, Raedler A, Schreiber S. Epidemiology of inflammatory bowel disease in a German twin cohort: results of a nationwide study. Inflamm Bowel Dis. 2008;14:968.CrossRefPubMedGoogle Scholar
  7. 7.
    Halfvarson J, Bodin L, Tysk C, Lindberg E, Jarnerot G. Inflammatory bowel disease in a Swedish twin cohort: a long-term follow-up of concordance and clinical characteristics. Gastroenterology. 2003;124(7):1767–73.CrossRefPubMedGoogle Scholar
  8. 8.
    Yang H, McElree C, Roth MP, Shanahan F, Targan SR, Rotter JI. Familial empirical risks for inflammatory bowel disease: differences between Jews and non-Jews. Gut. 1993;34(4):517–24.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Satsangi J, Welsh KI, Bunce M, Julier C, Farrant JM, Bell JI, et al. Contribution of genes of the major histocompatibility complex to susceptibility and disease phenotype in inflammatory bowel disease. Lancet. 1996;347(9010):1212–7.CrossRefPubMedGoogle Scholar
  10. 10.
    Bouma G, Strober W. The immunological and genetic basis of inflammatory bowel disease. Nat Rev Immunol. 2003;3(7):521–33.CrossRefPubMedGoogle Scholar
  11. 11.
    Cho JH, Weaver CT. The genetics of inflammatory bowel disease. Gastroenterology. 2007;133(4):1327–39.CrossRefPubMedGoogle Scholar
  12. 12.
    Eaden JA, Abrams KR, Mayberry JF. The risk of colorectal cancer in ulcerative colitis: a meta-analysis. Gut. 2001;48(4):526–35.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Chambers WM, Warren BF, Jewell DP, Mortensen NJ. Cancer surveillance in ulcerative colitis. Br J Surg. 2005;92(8):928–36.CrossRefPubMedGoogle Scholar
  14. 14.
    Oresland T, Bemelman WA, Sampietro GM, Spinelli A, Windsor A, Ferrante M, et al. European evidence based consensus on surgery for ulcerative colitis. J Crohns Colitis. 2015;9(1):4–25.PubMedGoogle Scholar
  15. 15.
    Mowat C, Cole A, Windsor A, Ahmad T, Arnott I, Driscoll R, et al. Guidelines for the management of inflammatory bowel disease in adults. Gut. 2011;60(5):571–607.CrossRefPubMedGoogle Scholar
  16. 16.
    Van Assche G, Dignass A, Bokemeyer B, Danese S, Gionchetti P, Moser G, et al. Second European evidence-based consensus on the diagnosis and management of ulcerative colitis part 3: special situations. J Crohns Colitis. 2013;7(1):1–33.CrossRefPubMedGoogle Scholar
  17. 17.
    Sheth SG, LaMont JT. Toxic megacolon. Lancet. 1998;351(9101):509–13.CrossRefPubMedGoogle Scholar
  18. 18.
    Robert JR, Sachar DB, Greenstein AJ. Severe gastrointestinal hemorrhage in Crohn’s disease. Ann Surg. 1991;213(3):207–11.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Silverberg MS, Satsangi J, Ahmad T, Arnott ID, Bernstein CN, Brant SR, et al. Toward an integrated clinical, molecular and serological classification of inflammatory bowel disease: report of a Working Party of the 2005 Montreal World Congress of Gastroenterology. Can J Gastroenterol. 2005;19(Suppl A):5A–36.CrossRefPubMedGoogle Scholar
  20. 20.
    Eaden JA, Mayberry JF. Guidelines for screening and surveillance of asymptomatic colorectal cancer in patients with inflammatory bowel disease. Gut. 2002;51 Suppl 5:V10–2.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Truelove SC, Witts LJ. Cortisone in ulcerative colitis; final report on a therapeutic trial. Br Med J. 1955;2(4947):1041–8.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Jakobovits SL, Travis SP. Management of acute severe colitis. Br Med Bull. 2005;75–76:131–44.PubMedGoogle Scholar
  23. 23.
    Van Assche G, D’Haens G, Noman M, Vermeire S, Hiele M, Asnong K, et al. Randomized, double-blind comparison of 4 mg/kg versus 2 mg/kg intravenous cyclosporine in severe ulcerative colitis. Gastroenterology. 2003;125(4):1025–31.CrossRefPubMedGoogle Scholar
  24. 24.
    Jarnerot G, Hertervig E, Friis-Liby I, Blomquist L, Karlen P, Granno C, et al. Infliximab as rescue therapy in severe to moderately severe ulcerative colitis: a randomized, placebo-controlled study. Gastroenterology. 2005;128(7):1805–11.CrossRefPubMedGoogle Scholar
  25. 25.
    Travis SP, Farrant JM, Ricketts C, Nolan DJ, Mortensen NM, Kettlewell MG, et al. Predicting outcome in severe ulcerative colitis. Gut. 1996;38(6):905–10.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Dignass A, Lindsay JO, Sturm A, Windsor A, Colombel JF, Allez M, et al. Second European evidence-based consensus on the diagnosis and management of ulcerative colitis part 2: current management. J Crohns Colitis. 2012;6(10):991–1030.CrossRefPubMedGoogle Scholar
  27. 27.
    Carter MJ, Lobo AJ, Travis SP. Guidelines for the management of inflammatory bowel disease in adults. Gut. 2004;53 Suppl 5:V1–16.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Rutgeerts P, Sandborn WJ, Feagan BG, Reinisch W, Olson A, Johanns J, et al. Infliximab for induction and maintenance therapy for ulcerative colitis. N Engl J Med. 2005;353(23):2462–76.CrossRefPubMedGoogle Scholar
  29. 29.
    Bolin TD, Wong S, Crouch R, Engelman JL, Riordan SM. Appendicectomy as a therapy for ulcerative proctitis. Am J Gastroenterol. 2009;104(10):2476–82.CrossRefPubMedGoogle Scholar
  30. 30.
    Gardenbroek TJ, Eshuis EJ, Ponsioen CI, Ubbink DT, D’Haens GR, Bemelman WA. The effect of appendectomy on the course of ulcerative colitis: a systematic review. Colorectal Dis. 2012;14(5):545–53.CrossRefPubMedGoogle Scholar
  31. 31.
    Mimura T, Rizzello F, Helwig U, Poggioli G, Schreiber S, Talbot IC, et al. Four-week open-label trial of metronidazole and ciprofloxacin for the treatment of recurrent or refractory pouchitis. Aliment Pharmacol Ther. 2002;16(5):909–17.CrossRefPubMedGoogle Scholar
  32. 32.
    Mimura T, Rizzello F, Helwig U, Poggioli G, Schreiber S, Talbot IC, et al. Once daily high dose probiotic therapy (VSL#3) for maintaining remission in recurrent or refractory pouchitis. Gut. 2004;53(1):108–14.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Gionchetti P, Rizzello F, Venturi A, Brigidi P, Matteuzzi D, Bazzocchi G, et al. Oral bacteriotherapy as maintenance treatment in patients with chronic pouchitis: a double-blind, placebo-controlled trial. Gastroenterology. 2000;119(2):305–9.CrossRefPubMedGoogle Scholar
  34. 34.
    Gionchetti P, Rizzello F, Helwig U, Venturi A, Lammers KM, Brigidi P, et al. Prophylaxis of pouchitis onset with probiotic therapy: a double-blind, placebo-controlled trial. Gastroenterology. 2003;124(5):1202–9.CrossRefPubMedGoogle Scholar
  35. 35.
    Subramanian V, Pollok RC, Kang JY, Kumar D. Systematic review of postoperative complications in patients with inflammatory bowel disease treated with immunomodulators. Br J Surg. 2006;93(7):793–9.CrossRefPubMedGoogle Scholar
  36. 36.
    Richards DM, Hughes SA, Irving MH, Scott NA. Patient quality of life after successful restorative proctocolectomy is normal. Colorectal Dis. 2001;3(4):223–6.CrossRefPubMedGoogle Scholar
  37. 37.
    Muir AJ, Edwards LJ, Sanders LL, Bollinger RR, Koruda MJ, Bachwich DR, et al. A prospective evaluation of health-related quality of life after ileal pouch anal anastomosis for ulcerative colitis. Am J Gastroenterol. 2001;96(5):1480–5.CrossRefPubMedGoogle Scholar
  38. 38.
    Brown SR, Travis SPL, Haboubi N, Hampton J, George B. The management of acute severe colitis: position statement of the Association of Coloproctology of Great Britain & Ireland. 2007.Google Scholar
  39. 39.
    Brady RR, Collie MH, Ho GT, Bartolo DC, Wilson RG, Dunlop MG. Outcomes of the rectal remnant following colectomy for ulcerative colitis. Colorectal Dis. 2008;10(2):144–50.PubMedGoogle Scholar
  40. 40.
    Trickett JP, Tilney HS, Gudgeon AM, Mellor SG, Edwards DP. Management of the rectal stump after emergency sub-total colectomy: which surgical option is associated with the lowest morbidity? Colorectal Dis. 2005;7(5):519–22.CrossRefPubMedGoogle Scholar
  41. 41.
    Wojdemann M, Wettergren A, Hartvigsen A, Myrhoj T, Svendsen LB, Bulow S. Closure of rectal stump after colectomy for acute colitis. Int J Colorectal Dis. 1995;10(4):197–9.CrossRefPubMedGoogle Scholar
  42. 42.
    Ng RL, Davies AH, Grace RH, Mortensen NJ. Subcutaneous rectal stump closure after emergency subtotal colectomy. Br J Surg. 1992;79(7):701–3.CrossRefPubMedGoogle Scholar
  43. 43.
    Phillips RK, Ritchie JK, Hawley PR. Proctocolectomy and ileostomy for ulcerative colitis: the longer term story. J R Soc Med. 1989;82(7):386–7.PubMedPubMedCentralGoogle Scholar
  44. 44.
    Nicholls J, Tekkis P. Ulcerative colitis. In: Phillips R, editor. Colorectal surgery. 3rd ed. Philadelphia: Elsevier Ltd; 2005. p. 129–62.Google Scholar
  45. 45.
    Ziv Y, Fazio VW, Sirimarco MT, Lavery IC, Goldblum JR, Petras RE. Incidence, risk factors, and treatment of dysplasia in the anal transitional zone after ileal pouch-anal anastomosis. Dis Colon Rectum. 1994;37(12):1281–5.CrossRefPubMedGoogle Scholar
  46. 46.
    Berry AR, de Campos R, Lee EC. Perineal and pelvic morbidity following perimuscular excision of the rectum for inflammatory bowel disease. Br J Surg. 1986;73(8):675–7.CrossRefPubMedGoogle Scholar
  47. 47.
    Bartels SA, Gardenbroek TJ, Aarts M, Ponsioen CY, Tanis PJ, Buskens CJ, et al. Short-term morbidity and quality of life from a randomized clinical trial of close rectal dissection and total mesorectal excision in ileal pouch-anal anastomosis. Br J Surg. 2015;102(3):281–7.CrossRefPubMedGoogle Scholar
  48. 48.
    Olsen KO, Joelsson M, Laurberg S, Oresland T. Fertility after ileal pouch-anal anastomosis in women with ulcerative colitis. Br J Surg. 1999;86(4):493–5.CrossRefPubMedGoogle Scholar
  49. 49.
    Bartels SA, D’Hoore A, Cuesta MA, Bensdorp AJ, Lucas C, Bemelman WA. Significantly increased pregnancy rates after laparoscopic restorative proctocolectomy: a cross-sectional study. Ann Surg. 2012;256(6):1045–8.CrossRefPubMedGoogle Scholar
  50. 50.
    Lepisto A, Sarna S, Tiitinen A, Jarvinen HJ. Female fertility and childbirth after ileal pouch-anal anastomosis for ulcerative colitis. Br J Surg. 2007;94(4):478–82.CrossRefPubMedGoogle Scholar
  51. 51.
    Brown CJ, Maclean AR, Cohen Z, Macrae HM, O’Connor BI, McLeod RS. Crohn’s disease and indeterminate colitis and the ileal pouch-anal anastomosis: outcomes and patterns of failure. Dis Colon Rectum. 2005;48(8):1542–9.CrossRefPubMedGoogle Scholar
  52. 52.
    Tulchinsky H, Hawley PR, Nicholls J. Long-term failure after restorative proctocolectomy for ulcerative colitis. Ann Surg. 2003;238(2):229–34.PubMedPubMedCentralGoogle Scholar
  53. 53.
    Melton GB, Fazio VW, Kiran RP, He J, Lavery IC, Shen B, et al. Long-term outcomes with ileal pouch-anal anastomosis and Crohn’s disease: pouch retention and implications of delayed diagnosis. Ann Surg. 2008;248(4):608–16.PubMedGoogle Scholar
  54. 54.
    Penna C, Dozois R, Tremaine W, Sandborn W, LaRusso N, Schleck C, et al. Pouchitis after ileal pouch-anal anastomosis for ulcerative colitis occurs with increased frequency in patients with associated primary sclerosing cholangitis. Gut. 1996;38(2):234–9.CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    Choen S, Tsunoda A, Nicholls RJ. Prospective randomized trial comparing anal function after hand sewn ileoanal anastomosis with mucosectomy versus stapled ileoanal anastomosis without mucosectomy in restorative proctocolectomy. Br J Surg. 1991;78(4):430–4.CrossRefPubMedGoogle Scholar
  56. 56.
    Kirat HT, Remzi FH, Kiran RP, Fazio VW. Comparison of outcomes after hand-sewn versus stapled ileal pouch-anal anastomosis in 3,109 patients. Surgery. 2009;146(4):723–9. discussion 9-30.CrossRefPubMedGoogle Scholar
  57. 57.
    Nicholls RJ, Pezim ME. Restorative proctocolectomy with ileal reservoir for ulcerative colitis and familial adenomatous polyposis: a comparison of three reservoir designs. Br J Surg. 1985;72(6):470–4.CrossRefPubMedGoogle Scholar
  58. 58.
    Danese S, Semeraro S, Papa A, Roberto I, Scaldaferri F, Fedeli G, et al. Extraintestinal manifestations in inflammatory bowel disease. World J Gastroenterol. 2005;11(46):7227–36.CrossRefPubMedPubMedCentralGoogle Scholar
  59. 59.
    Lichtiger et al. Cyclosporine in severe ulcerative colitis refractory to steroid therapy. N Engl J Med 1994; 33:1841–5.Google Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2017

Authors and Affiliations

  1. 1.Department of Colorectal SurgeryRoyal Berkshire HospitalReadingUK
  2. 2.Department of Colorectal SurgeryOxford University Hospitals, Churchill HospitalOxfordUK

Personalised recommendations