Complications Of Ulcerative Colitis

Ulcerative colitis has a number of potential complications that need to be attended to right away to avoid life threatening complications. Six of the more common complications are discussed here.

1. Toxic Colitis

The ulcerations usually are quite superficial with ulcerative colitis.

These conditions are very serious and have a high death rate even with treatment. The ileus can be seen on x-rays as dilated bowel loop with gas and fluid levels in it. Because of a lack of bowel propulsion in this segment, it functions like a block and nothing will move through the gut. The patients looks sick, have a high fever and vomit. Peritonitis leads to severe abdominal pain and a high fever and there is a rigid abdomen. A surgeon needs to be called in case of an underlying bowel perforation and antibiotics need to be given fast before sepsis and shock set in.

2. Massive Rectal Hemorrhage

Although bleeding is normally part of the clinical presentation of ulcerative colitis, in a minority of patients there is a sudden deterioration with profuse blood coming out with every bowel movement and the bowel movements are getting more and more frequent. This is an emergency situation as the patient could bleed to death, if left alone.

In this case a general surgeon needs to be called in on an emergency basis and he/she will likely do a partial removal of the bleeding colon (called "subtotal colectomy"), make an artificial opening for the cut ileum through the abdominal wall ( called " ileostomy") and close the rectosigmoid stump at that time. When this emergency procedure was tolerated, the patient usually improves dramatically, as the rectal bleeding now has stopped and the nutritional status improves as well. In the future, further surgery can then be performed on an elective basis when the patient's state is more stable. This would consist of removal of the rectosigmoid portion that was left behind, otherwise ulcerative colitis could recur in that portion of the large intestine. At the same time an intestinal pouch fashioned out of ileus tissue can be transferred into the pelvic area to replace the lost rectum and the procedure is completed by connecting the intestinal pouch with the anus (called "ileoanal anastomosis"). The intestinal pouch serves as a reservoir for stool, which cuts down on the amount of stools per day and makes the stools more formed.

3. Acute Perforation

Another complication that is life threatening is when one of the ulcers of the large intestine perforates. As the disease is usually most severe in the sigmoid colon area, this likely will be the area where one of the deep ulcers perforates. This is an emergency, because bowel contents with lots of E.coli and other bacteria flow freely into the abdominal cavity. The general surgeon needs to do open the abdomen (do a" laparotomy") and look for the area of perforation. The surgeon likely will do the same procedure as described under point 2 above (emergency "subtotal colectomy"). Once ulcerative colitis has progressed to such a point that there is perforation, the chances that this will happen again soon in another diseased location are very high. It makes therefore sense to do what appears to be a rather invasive procedure.

4. Cancerous Degeneration

This is why any patient, once ulcerative colitis has been known to be present for more than 8 years, should have regular colonoscopies (endoscopic examinations with a fiberoptic instrument) through a gastroenterologist. This will allow to screen for mucosal dysplasia. Once this has been diagnosed for the first time, the patient should be scheduled immediately for an elective total colectomy as this is an indication that there has been a deterioration of the ulcerative colitis and there will be cancer in the very near future. Often at the time of surgery, there is already early cancer in another area, that might have been missed with the colonoscopy. This is an emotional topic, but the patient needs to understand that total colectomy is presently the only alternative to dying later of colon cancer. Once this has been done, the patient has a normal life expectancy. In the past these patients had to get used to live with an ileostomy (changing pouches etc.). Now there is an alternative with doing an ileoanal anastomosis using an intestinal pouch, in which case there are normal bowel movements and no more risk of a recurrence of ulcerative colitis. This is so, because ulcerative colitis never goes beyond the limit of the colon.

5. Primary Sclerosing Cholangitis

In about 5% of patients with ulcerative colitis a severe obstructive form of cholangitis develops in the bile ducts of the liver and the bile ducts. This leads to jaundice and a chronic skin itch.

The physician can arrange for an ERCP (endoscopic retrograde cholangiopancreatography) to visualize the strictures in the bile ducts. The gastroenterologist will attempt to localize a stricture and possibly place a stent to overbridge it. But each case is different. The longer the patient has had ulcerative colitis or Crohns disease, the higher the danger of this complication. Unfortunately, there is also a high incident of cancer in the bile ducts ("cholangiocarcinoma") that develops in these patients. The link between Crohns, ulcerative colitis and primary sclerosing cholangitis might be due to severe changes in the immune system, where autoimmune phenomena have been described both in terms of autoimmune antibodies as well as autoimmune T lymphocytes. More research needs to be done in this area before new less invasive therapies will be available.

6. Other complications:

A group of patients, often associated with the cell surface antigen HLA-B27, have arthritis of the major joints, lower back pain (due to ankylosing spondylitis and sacroiliitis) and growth retardation in children. Other potentially dangerous conditions are recurrent inflammatory eye conditions (episcleritis and uveitis), for which an eye specialist should be consulted for appropriate treatment. Often symptoms of these conditions can precede ulcerative colitis by many years.

Disclaimer:

This outline is only a teaching aid to patients and should stimulate you to ask the right questions when seeing your doctor. However, the responsibility of treatment stays in the hands of your doctor and you.

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Last Modified: Dec. 17, 2006