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Ulcerous Colonitis

 

Kolitis ulzerosa

 

What is an ulcerous colitis?

The ulcerous colitis is a chronic inflammatory disease of the mucous membrane of the large bowel, which often first occurs in the rectum. Then, it normally spreads backwards, i.e. towards the appendix and into the complete large bowel "frame". Concerning the causes for the ulcerous colitis, various factors are assumed: there are familial accumulations, and there are indications of a disturbed immunological system. Further, there is the suspicion that viruses and bacteria might trigger the disease. Women are affected by the disease more often than men. Normally, this disease develops intermittently, which means that the patients may possibly remain without complaints for years until the inflammation reoccurs. If the mucous membrane is examined during an attack, highly inflamed areas are found with the formation of abscesses, so-called ulcerations. If the inflammation subsides, the healthy mucous membrane between the ulcerations reacts by excessively producing cells, which then appear as proliferations of the mucous membrane (polyps). The ulcers, however, heal and form scars, which leaves the intestinal wall rigid (like a pipe) and deprived of its function. Looking at this disease under the aspect of surgery, it is important to realize that the probability of developing thus a carcinoma of the colon rises the longer the disease lasts (>10 years). And there is the risk that the whole colon will be affected, requiring special surgical measures in this context. After these short explanations, the special surgical measures are described below.

How do I recognize an ulcerous colitis?

Characteristic of an ulcerous colitis are mucous and bloody diarrhoeas, which may occur up to 20 times per day. They are accompanied by pains and convulsive complaints around the "frame" of the large bowel, the rectum, and the sacral bone. Bloating, fever, rise of the indicators of inflammation in the blood, loss of weight and protein may also occur. The acute beginning of the disease, but also new intermittent attacks, may go along with certain other complications. There may be an acute overdistension of the large bowel (toxic megacolon), considerable bleedings around the ulcerations, forming of abscesses, and/or perforation of the intestinal wall. In these cases, surgical intervention becomes urgently necessary.

Necessary clarifications and diagnostic possibilities

At the latest when a patient discovers blood and mucus in his stool, he should consult a doctor for the necessary clarifications. The doctor must first of all try to carefully question the patient about bleedings, loss of weight, fever, and pains as a basis for further diagnostics. He has to palpate the "frame" of the colon for pain on pressure and digitally examine the rectum of the patient. Then, a laboratory examination is to follow, which should comprise above all important parameters indicative of inflammation. A colonoscope including biopsy and bacteriology may help to confirm the diagnosis, and an X-ray examination of the colon with water-soluble contrast material should show if the structure of the intestinal wall has changed. No single indication or symptom alone proves the existence of an ulcerous colitis. Only the overview of all findings can result in the correct diagnosis, as there are other diseases of the colon with the same complaints.

How can an ulcerous colitis be treated?

An acute attack of the disease is treated with large-dosed cortisone and special anti-inflammatory medicaments, abstinence from food and intravenous administration of liquid. This treatment may have to be carried out for a long time. Here, we would like to present the surgical method which is used if a carcinoma of the colon is found in addition to the colitis or if the consequent conservative therapy has failed: the continence-preserving proctocolectomy with J-pouch installation.

Patients, who have had a colitis ulcerosa for a long time, have to regularly undergo a coloscopy, as there is a high probability that this disease is linked with the development of a carcinoma. If a carcinoma is diagnosed, the whole large bowel has to be removed because there is the danger that another carcinoma develops after some time in a different place. If the great bowel including the rectum is totally removed, as it is the case in a proctocolectomy, the patient is left without the part of the colon thickening the chyme, but also without the rectal ampulla as stool reservoir. The rectal ampulla and the anus with its special musculature are tuned to each other in a complicated way. Together, they constitute the anatomical unit making rectal continence possible. Patients who have undergone a proctocolectomy have therefore to be supplied with an artificial anus (ileostoma) for many years. The ileostoma serves the purpose of evacuating stool and gas of a section of the small bowel through the abdominal wall into a bag. In the meantime, a surgical method has been developed, which aims at the formation of a stool reservoir from a loop of the small bowel (J-pouch). It gives to the patient the possibility of evacuating the stool through the anus. This method can be applied if the patient has no anal disease and if the sphincter muscle functions well. Nevertheless, this operation is a big intervention, and the installation of J-pouch has got advantages and disadvantages, which have to be carefully explained in advance. This will be discussed again in the last chapter.

When the surgeon starts with an operation of a proctocolectomy, the incision is made a few centimetres above the navel and then around it to the left and further down up to the pubic hair line. After this, the abdominal wall is severed layer by layer until the abdominal cavity is opened. The surgeon assesses all organs such as liver, spleen, and stomach with his hand for the sake of orientation. He wants to find out whether there are any enlarged lymphatic nodes or metastases. Then, he looks for the ascending colon to the right side and for the appendix (caecum), which is the section of the large bowel into which the small bowel leads. Starting at this place, the complete "frame" of the large bowel must be released. For this purpose, the colon is carefully pushed away from the peritoneum, and the suspensory ligaments to the diagonal part of the stomach are severed. Then, the descending large bowel in the lower abdomen is also loosened from the peritoneum. The small bowel is then separated in a suitable place from the large bowel near the caecum. For this, a linear stapling device is used which severs the colon and at the same time closes it. The vessels that lead to the sections of the great bowel to be later removed are exposed and tied up, and the great bowel is mobilized up to the sigma. During this phase of the operation, the surgeon checks again and again whether the urinary duct on both sides remained uninjured. Then, the rectum is carefully detached from the tissue of the small pelvic cavity, almost, as far as to the anus. Now, the surgeon checks whether the length of the small bowel loop is long enough to reach the lowest section of the rectum, so that later a tension-free connection with the new reservoir will be possible. The operation is then carried on from the anus. About 1 - 2 cm from the anus, the mucous membrane of the rectum is removed, but with the muscular mantle of the rectum being maintained. The already mobilized large bowel and the rectum are removed at the place, where the mucous membrane had been enucleated. The reservoir (pouch) is formed from the lower loops of the small bowel by turning up the end of the small bowel in the form of a J. Then, the two walls are sutured side by side. After this, the small bowel reservoir is carefully pulled down towards the anus and stitched to the muscular layer of the rectum in the area of the constrictor. An opening of 1.5 cm is cut into the tip of the J-formed pouch and sutured to the layers of the rectum. To reduce the strain on the anastomosis near the anus, the surgeon installs a provisional ileostoma in the right lower abdomen. For this purpose, a small round incision is made and the abdominal wall is cautiously opened there. A small section of the small bowel is pulled to the outside through this opening; the bowel is opened and sutured to the skin. Through this opening, the content of the bowel can discharge into a bag during the following months, so that the new reservoir can still rest and all sutures can heal. Finally, the surgeon carefully checks to make sure that there is no bleeding. Two drainages are laid, and the abdominal wall is closed layer by layer.

What happens after the treatment?

Every patient is observed for 1 - 2 days at the intensive care unit. Important laboratory factors are controlled, an extensive pain therapy is carried out, a sufficient amount of infusions made, and antibiotics are applied. This is important as the patient loses great quantities of liquid through his ileostoma due to the fact that the large bowel cannot thicken the chyme any more. Normally, these quantities diminish in the course of time, however. The patient is then made to walk around and is assisted by stoma advisors to learn how to take care of the artificial anus and how to use the necessary accessories. The ileostoma will relieve and protect the suture at the anus and is later transferred back in another operation. The small bowel is for that reason carefully loosened from the abdominal wall and then mobilized. The section of the small bowel that had served as a stoma is removed and put together again. During this operation, the surgeon will also assess the suture at the rectum and the condition of the reservoir from the anus and make corrections if necessary. After the translocation of the ileostoma, the patient will have frequent evacuations of the bowels through the reservoir (10 - 12 times per day). This high frequency is, however, reduced to 4 - 6 times per day after some months. Here, a complication connected with the installation of a pouch has always to be mentioned and explained if such an operation is considered: the pouchitis, an unspecific inflammation of the small bowel reservoir. Its cause has not been entirely clarified: whether it is a bacterial infection, a continuation of the colitis in the small bowel, or whether there are certain changes in the metabolism of the mucous membrane of the colon. About 40% of the patients that carry a pouch suffer from one or several such inflammations of the reservoir. Normally, a treatment with antibiotics is successful even if it is not quite known whether bacteria are the cause of the inflammation or not. Only very rarely, this complication turns chronic, which makes the removal of the pouch eventually necessary. Half of the patients with a pouch never suffer from such inflammations, or the inflammations are minimal. Apparently, individual factors also play a role in the development of this complication.

History

Still 150 years ago, about two thirds of the patients with intestinal hernia operation died. Even after smaller interventions like the amputation of toes or fingers, 10% of the patients died. The reasons for this high mortality were lacking anaesthesia, antisepsis, and the shock problem. Shock can be caused by severe loss of blood or bacteria that seeped in and may result in death. But then, pioneering discoveries were made, constituting the firm foundation for every great abdominal surgery. Horace Wells realized the first narcosis in 1844 using laughing gas, and in 1901, Karl Landsteiner discovered the blood groups of the human being. This furnished the possibility to perform blood transfusions during great surgical operations and to successfully treat the blood-loss shock. However, the greatest achievement was the finding of Ignatz Philipp Semmelweiss that the wound infections at that time were mostly fatal, especially the childbed fever, because of lacking hygiene of hands and instruments. Until then, an intensive disinfection of the hands was entirely unknown in hospitals. Without knowing it, one carried the bacteria from one patient to another. Unfortunately, Semmelweiss was too progressive for his time, so that his appeals for a disinfection of the hands with carbolic acid, even if proved effective, were at first not taken seriously by many doctors, among them the famous discoverer of the bacteria, Luis Pasteur. It was the surgeon Joseph Lister in Glasgow, who had heard of Semmelweiss' ideas and used them with success in his hospital in 1867. The hands of the surgeons were washed with soap containing carbolic acid before the operations, and a carbolic solution was sprayed over the area of surgery during the operation. This reduced the number of fatal complications after operations considerably. Because of these findings, operation theatres were built that could only be entered with mouth guard and head bandage. This was the reason why the first great and aseptically carried out abdominal surgeries were much more successful from 1880 onwards. An example for the sense of a new era in abdominal surgery, due to the new conditions mentioned, is the work of the surgeon Ulrich Kroenlein, who worked and taught at the University Hospital at Z?h since 1881. He put the new sanitary ideas into action in his hospital by having the floors tiled, by removing bedsteads made of wood, and by building a new surgery for instruction in the form of an amphitheatre. As one of the first surgeons, Kroenlein operated cases of acute appendicitis and worked on the therapy to fight purulent peritonitis, which occurred after injuries of the bowels. In order to avoid peritonitis that occurred because of bad sutures of the bowel (anastomosis), two other famous surgeons of that time made an effort to develop new suturing techniques in abdominal surgery: Theodor Kocher and Vinzenz Czerny. Theodor Kocher writes in 1894: "The intestinal resection has become an extraordinarily important and comparatively frequent surgical intervention, by which the surgeon can save many lives otherwise being considered lost if he carries it out correctly." At the same time, he introduced his running perineal suture. This is why Sir Ernest Miles was able to carry out the first radical abdominoperineal resection of a rectum carcinoma, a very great intervention, in which the colon and the rectum are completely removed.

 

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