Surgery for ulcerative colitis: What to know
The Crohn's and Colitis Foundation say 25 to 40 percent of people with ulcerative colitis eventually require surgery.
Today, there are two different surgical techniques for ulcerative colitis. The type of surgery a person has will depend on their symptoms, age, other health conditions, and personal preference.
After surgery, most people with ulcerative colitis can lead healthy, active lives. Learn more about the procedures and what to expect in this article.
What is ulcerative colitis surgery?
A person may need ulcerative colitis surgery if other treatments, such as medication, do not control their symptoms.
A person may also need surgery if they have colon cancer or precancerous changes in the colon.
Having ulcerative colitis raises a person's risk of developing colon cancer, especially if they have had ulcerative colitis for 8 years or more.
Sometimes, people with ulcerative colitis need emergency surgery if they have a perforation (hole) in the colon or bleeding that will not stop.
There are two types of ulcerative colitis surgery:
Proctocolectomy with ileostomy
Ulcerative colitis surgery may involve doctors creating a new opening for the intestine outside the body.
Proctocolectomy with ileostomy involves the following steps:
- Removing the large intestine (colon and rectum) and anus.
- Moving the end of the small intestine (the ileum) to a spot in the lower abdomen, usually on the right side.
- Making an opening in the lower abdomen known as a stoma.
- Bringing the end of the ileum through the stoma and attaching the intestine to the skin. This creates an opening from the small intestine to the outside of the body.
- Attaching a bag called an ostomy pouch to the opening, which allows waste from the small intestine to empty into the pouch. A person will empty the pouch into the toilet throughout the day.
The stool that comes out of the small intestine is not solid, and so it can flow into the pouch without the individual noticing.
The stoma does not have a muscle, and people cannot control when the pouch fills up. Ostomy bags available today are flat, discreet, and odor-free.
People wear an ostomy bag under their clothes, where it is not noticeable. Special garments are also available that conceal the ostomy bag for intimacy.
After a person has a proctocolectomy with ileostomy, they will need to learn to care for their stoma and the ostomy pouch. As well as regularly draining the pouch, they must learn to clean the stoma area to avoid infections.
Some pouches are washable and reusable, while others are disposable. The type of pouch will depend upon a person's preference.
Proctocolectomy and ileoanal pouch-anal anastomosis (IPAA)
IPAA surgery is a procedure that avoids the need for a permanent ostomy bag.
Proctocolectomy and ileoanal pouch-anal anastomosis (IPAA) is a newer procedure that allows a person to have bowel movements out of their natural anal opening. This procedure is sometimes called ileoanal pouch reservoir surgery or J-pouch surgery.
IPAA preserves the anus, rather than removing it. This procedure involves the following steps:
- Removing the colon and rectum, but keeping the anus intact.
- Using the small intestine to create an internal pouch that collects the body's waste. This pouch is sometimes called a J-pouch or ileoanal reservoir.
- Connecting the internal pouch to the anus.
Stool gradually collects in the internal pouch and exits the body via the anus, making it more like a standard bowel movement.
If a person's anal muscles are in good condition, they will be able to feel stool coming out and will be able to use the toilet for bowel movements, as usual.
Although a surgeon preserves the anus with this procedure, the bowel movements are often more frequent and may be very soft or watery because the colon is missing.
Fecal incontinence (having an accident) may occur in some people, but medications are available that can help control bowel movements. A person should have good functioning of the anal muscles to help reduce the risk of incontinence.
Sometimes, surgeons perform IPAA in stages. The first stage involves making the pouch and connecting it to the anus. Then, the surgeon will leave the pouch alone to heal for several weeks.
The surgeon creates a temporary stoma and ostomy bag for use until the second procedure takes place.
After 2–3 months, they will close the temporary stoma in the abdomen and re-route the waste to the internal pouch and out via the anus.
How to prepare
Preparation for ulcerative colitis surgery depends upon the type of surgery. A doctor will provide detailed instructions in advance.
In general, people must completely empty their bowel before surgery using a "bowel prep." The person may need to drink a laxative solution, take antibiotics, and eat no solid foods for a day or two before surgery.
Ask a doctor about any medications or supplements to be sure they are safe to take before surgery. It may be possible to take some with a small sip of water, but a person may need to stop taking some other medications until after surgery.
A surgeon may perform ulcerative colitis surgery, using a long incision in the abdomen. This is called an open surgery and often means a person will need to stay in the hospital for several days to recover.
In some cases, the surgeon may be able to use minimally invasive techniques with smaller incisions. This is called laparoscopic surgery.
People who have a laparoscopic procedure may be able to go home sooner than those who have open surgery.
However, full recovery after either type of ulcerative colitis surgery often takes several weeks.
Immediately after surgery, the person will go to a recovery area and may have drainage tubes connected to their abdomen, as well as a catheter for the release of urine.
After the person wakes up, the surgeon will discuss when the tubes will be removed and may advise a person to get up and start walking, as soon as it is safe to do, to help prevent blood clots.
The medical team will provide pain relief in the hospital and may prescribe pain-relievers to use at home.
A doctor can explain the potential risks and benefits of ulcerative colitis surgery.
The most common issue for people who have an ileostomy is a blockage in the small intestine. Symptoms of a blockage include:
- severe abdominal pain
- thin, clear, foul-smelling liquid in the pouch
- dark-colored urine
- lack of liquid in the pouch
- swelling around the stoma
A person should call a doctor immediately or go to the emergency room if they are experiencing symptoms of a blockage.
People who have IPAA surgery will need to watch for symptoms of pouchitis. This is an infection of the internal pouch that requires antibiotics.
About half of all people who have IPAA surgery get pouchitis at least once. Symptoms of pouchitis include:
Sometimes the small intestine can get blocked after IPAA surgery, but this problem is less common. Most of the time, a person can recover from a blockage following an IPAA surgery with a short stay in the hospital and intravenous fluids.
Dietary changes after surgery
After ulcerative colitis surgery, a person may need to change their diet. Without a colon, the body digests food differently.
Some people may need to take vitamins or supplements to ensure they get enough nutrients. A doctor or dietitian can help a person make an individualized meal plan after they have had surgery.
People may find that certain foods cause diarrhea or digestive problems following surgery. When trying new foods, it is wise if they introduce only a little at a time to minimize any possible issues.
While problematic foods vary from person-to-people, many find it best to avoid the following foods to minimize discomfort and diarrhea:
- dried fruit, such as prunes, figs, and raisins
- raw fruits and vegetables
- nuts and seeds
- spicy foods
- high-sugar foods, such as candy
- carbonated drinks or drinks with caffeine
Eating small meals more frequently can also help avoid gas and pressure from an empty stomach.
Foods that are "binding," such as bananas, potatoes, and rice may also be helpful. Drinking plenty of water can help offset dehydration from loose stools. Staying hydrated also helps keep the intestines working well.
While ulcerative colitis surgery is a significant life change, the outcome is often positive overall, as surgery may permanently relieve some symptoms.
Deciding upon the type of surgery and when to have it can be difficult, but a doctor can discuss all the options.
In addition, support groups and forums for people with ulcerative colitis can be helpful, not only for deciding about surgery but also for receiving ongoing emotional support.