Professor. IAN T. JONES FRACS FRCS COLORECTAL SURGERY Suite 5, 6 & 7 Private Medical Centre Royal Melbourne Hospital Royal Parade Parkville VIC 3050 Telephone: 9347 4077 Facsimile: 9348 2075 Pager: 9387 1000 ULCERATIVE COLITIS AND CROHN’S DISEASE INTRODUCTION Ulcerative colitis and Crohn’s disease are sometimes grouped together as examples of inflammatory bowel disease (IBD). These are disorders characterised by chronic inflammation of the gastrointestinal tract which can lead to swelling and ulceration of the intestines. Crohn’s disease can affect any part of the intestinal tract from the mouth to the anus whilst ulcerative colitis is confined to the colon (large intestine). The diseases are very similar and can cause a range of symptoms including diarrhoea, rectal bleeding, abdominal pain, weight loss and a feeling of poor health. The diseases are not rare but the conditions only develop in about twenty (20) people out of every 100,000 in the population. The cause of inflammatory bowel disease is unknown although most theories concentrate on a defect in the body’s immune system or a possible infective agent. There is a tendency for the condition to run in families. DIAGNOSIS A thorough history and physical examination are an important starting point particularly by a specialists who regularly treats these conditions including colorectal surgeons and gastroenterologists. Sometimes these specialists act together in the treatment of the patient. A number of tests may be required to confirm the condition including blood tests, colonoscopy, gastroscopy and CT scans. TREATMENT As for any chronic inflammatory disease, anti-inflammatory medications are frequently used. These can include drugs like sulfasalazine, mesalazine, prednisolone (a cortisone type drug), antibiotics (including metronidazole and ciprofloxacin) and special medications that modify the body’s immune response including azathioprine, cyclosporine and infliximab. The administration and monitoring of these medications usually requires the assistance of a specialist in inflammatory bowel disease. SURGERY When medications fail to bring the inflammatory bowel disease under control, when there are significant side effects from medications or when complications occur, surgery may be required. The nature of the surgery depends on the reason the surgery is being undertaken and the particular site in the gastrointestinal tract where the inflammation has occurred. Examples of the type of operation that might be required for inflammatory bowel disease are listed below. 1. Ulcerative Colitis In this condition, the inflammation is confined to the large intestine but if surgery is required, it is often all of the large intestine that is involved. In view of that, when an operation is carried out most of the large intestine (colon and rectum) will need to be removed. These operations are called proctocolectomy, total colectomy and ileorectal anastomosis and proctocolectomy with ileoanal pouch reconstruction. Whilst these are big operations, in most cases a stoma such as an ileostomy (where an external pouch is placed over the end of the intestine which is brought to the abdominal wall to discharge the waste material, is not required). Crohn’s Disease Crohn’s disease is commonest at the junction of the small and large intestine (ileocaecal region). In view of that, perhaps the commonest operation carried out for Crohn’s disease is resection of the ileocaecal region. In most cases, the bowel ends are rejoined (anastomosis). In other cases, only a segment of small intestine may need to be removed or a stricture or narrowing of the small intestine repaired (strictureplasty). Sometimes the colon is affected in Crohn’s disease and removal of the colon might be required. Crohn’s disease can also affect the anorectal region causing fissures and abscesses and various types of anal operation can be required for treatment of patients with anal Crohn’s disease. 2. FOLLOW UP AND PROGNOSIS Inflammatory bowel disease is a long term condition usually requiring regular specialist supervision and medication. Despite this, the majority of patients enjoy a good quality of life and are able to carry out normal family and employment responsibilities. If surgery is required, a specialist colorectal surgeon is most qualified to undertake this and in the vast majority of cases patients return to their normal life, often with an improved quality of life because the underlying problem has been dealt with surgically. Diet is of interest and importance in the management of inflammatory bowel disease but to date there is no evidence that dietary factors cause the condition. It is important for patients with inflammatory bowel disease to maintain adequate nutritional intake to avoid problems such as weight loss or malnutrition which can occur if the diet is deficient. The risk of intestinal cancer is moderately increased in patients who have suffered from inflammatory bowel disease for ten years or more. In view of that, patients who have had Crohn’s disease or ulcerative colitis for several years will frequently be recommended to undergo surveillance examinations such as colonoscopy. For patients with ulcerative colitis, medications can often maintain the condition in remission indefinitely. Just as in the case of other inflammatory conditions such as arthritis, medications control but cannot cure ulcerative colitis. If surgery is required however, removal of the colon is a curative procedure as in that situation all of the disease affected part of the intestinal tract is removed permanently. For patients with Crohn’s disease, the situation is a little less straightforward. Because Crohn’s disease can affect any part of the intestinal tract, neither antiinflammatory medications or surgery can permanently cure the condition as it may recur in other parts of the intestinal tract. However the vast majority of patients with Crohn’s disease have improved quality of life on medication or when surgery is required and their overall prognosis for living a normal life span is only slightly reduced compared to the population at large. USEFUL SOURCES OF INFORMATION 1. Your specialist colorectal surgeon or gastroenterologist. 2. The Colorectal Surgical Society of Australasia www.cssa.org.au 3. The Australian Crohn’s and Colitis Association www.acca.net.au 4. The Crohn’s and Colitis Foundation of America www.ccfa.org 5. The Cleveland Clinic Foundation Digestive Diseases Centre www.clevelandclinic.org/digestivedisease These information sources offer helpful information of a general nature. For advice about your own particular circumstances, the best source of information is from your treating specialist.