15402272

Case Report 1.

Presenting complaint:
Patient is a 24 year old man who is 4 days post op after a total colectomy and end ileostomy formation.

History of presenting complaint:

The patient initially presented to his GP with a 2 month history of severe abdominal cramps, persistently
bloody diarrhoea with accompanying mucus, in addition to approximately 2.5kg unintentional weight loss
and increasing tiredness.
His symptoms started with cramping in the abdomen, with a strong urge to pass stool after eating. Within a
month, passage of stools became more frequent (up to 7 times a day) and stools were persistently watery
mixed with fresh blood and water. The patient's quality of life was greatly impacted, he is a teacher and had
to take time off work. He attended an out of hours GP and was treated for gastritis.
Symptoms persisted and worsened. He began to vomit after eating, which lasted for 8 days, after which he
was admitted to the Mater Misericordiae Hospital for rehydration and further investigations. Stool studies
ruled out a possible infection e.g. clostridium difficile or E. Coli and colonoscopy and histology supported a
diagnosis of ulcerative colitis. No toxic megacolon was present on abdominal radiograph. The patient was
initially managed medically, with rehydration, IV methylprednisolone and morphine. This continued for 1
week, with the addition of infliximab after three days, as there had been no marked response to the initial
therapy.
After 7 days, clinical remission had not been induced and the patient's symptoms were still not controlled. It
was decided therefore that the medical treatment was not sufficient and that surgical management was
required.
A laparoscopic total abdominal colectomy and end ileostomy was carried out, without any complications.

Past Medical/Surgical history:

No past surgical history.
No past medical history of note.

Medications:
NKDA
On no regular medications prior to surgery.
Paracetamol 1g IV every 6 hours
Dexamethasone 8mg
Lactated Ringer's solution 50ml/hour IV

Family history:
He is an only child, with mother and father both alive and well and living in Wexford.
No known history of colon disease in the family.

Social history:
A primary school teacher, the patient lives with 3 housemates in Santry. He is a non-smoker and used to
drink approximately 15 units of alcohol on the weekend, but not during the week.

Review of systems:
Nil of note.

Examination:
On clinical examination, the patient was alert, orientated and was breathing room air comfortably. He had an
IV line in his left cubital fossa and an ileostomy bag was situated in the right iliac region, which contained
some fluid. There were small dressings on the laparoscopic port sites, but there was no redness around the
dressings, and they were only slightly tender. The patient reported no problems drinking liquids and had
begun to eat a small amount of solid food also.

Discussion.
Pathophysiology:
Ulcerative colitis is a chronic disease which is associated with diffuse mucosal inflammation of the colon,
resulting in symptoms such as bloody diarrhoea, tenesmus and rectal urgency. It most commonly involves
the rectum and then spreads in a continuous manner throughout the colon.
The typical onset of symptoms occurs between the ages of 15-30 years of ages, but there is also a second
peak between the ages of 50 and 80 years of age (1). Factors which can affect the disease course include
the patient's age at diagnosis, the extent and severity of the disease and the response to treatment with
regards to its effect on mucosal healing.
A study found that patients with early onset ulcerative colitis diagnosed between the ages of 18 and 30
years of age were less likely to experience a steroid-free remission versus patients diagnosed aged 50 or
over. (2) (3)

The exact pathophysiology of ulcerative colitis is not completely understood, however it is widely believed
that the disease is caused by an inappropriate over response of the immune system to a stimulus in the
colon (4). The immune system in the colon is constantly reacting to stimuli from commensal microflora and
food. Mucosal dendritic cells and local T cells play a key role in regulating this response to induce a state of
tolerance therefore any breakdown in this system can lead to the two main forms of inflammatory bowel
disease, one of which is ulcerative colitis and the other being Crohn's disease. Tumour necrosis factor α is
elevated in the blood, stool samples and mucosa of patients with ulcerative colitis, and so this, coupled with
the evidence of anti TNF being an effective treatment for ulcerative colitis, indicates that TNF α plays a
significant role in the pathogenesis of this condition (5)

Choice of surgical procedure

Immediate surgical management of ulcerative colitis is required with a patient is refractory to medical
treatment or when serious complications arise, for example massive life threatening haemorrhage, toxic
megacolon or colonic perforation (6). In the case of such complications, surgery is required immediately. (7).
In this case, surgery was urgently needed, as the patient was not responding to the medical approach and
so it was decided to perform a laparoscopic total colectomy and ileostomy. This removed the entire colon
but leaves behind a defunctionalized rectum as a Hartman's pouch. This procedure was chosen as it is the
preferred method in urgent situations, due to being a simple procedure that can be carried out quickly.
Disadvantages to this procedure include that it requires a second operation and may develop a rectal
recurrence of the disease in the meantime.

Other treatment alternatives.

Elective surgery indications include patients who have a significant risk of developing colorectal cancer,
mucosal dysplasia or an intolerance to the medical management of their condition.
In elective settings, there are 4 main surgical options for management of ulcerative colitis
- Restorative proctocolectomy with ileal pouch anal anastomosis
- A two stage, completely restorative procedure, but which has a high risk of septic
complications. The prevalence of pouch-related septic complications in patients with
ulcerative colitis is approximately 24% (8)
- Total abdominal colectomy with ileorectal anastomosis
- this is infrequently performed as diseased rectum remains, increasing the risk of persistent
inflammatory symptoms (9)
- Proctocolectomy with permanent ileostomy (Brooke).
 - More commonly done in elderly patients who want to avoid the risks of an IPAA and who may
have poor sphincter function.
- Proctocolectomy with continent ileostomy (Kock)
Both the Brooke ileostomy and continent ileostomy result in a permanent end ileostomy, while the other 2
procedures involve a gastrointestinal reconstruction.

Expected and potential outcomes.

Now that the patient is stabilized, a complete proctectomy can be performed at a later time, as a total
proctocolectomy and staged ileal pouch anal anastomosis is the preferred option for patients with ulcerative
colitis which is refractory to medical therapy (10)
Not every patient will be suitable for an IPAA, so it is important to advise a patient that a permanent
ileostomy will the required if an IPAA is not technically possible, or if the /pouch fails due to anastomotic
complications such as poor function or infection. A patient who receives a permanent ileostomy must be
counselled and taught how to manage it, including cleaning and changing procedure and this is usually done
by a designated stoma nurse.
If a pouch is formed, it must be followed up after 4 weeks with a barium radiographic study, to ensure there
is not an anastomotic leak and after 8 weeks with anal manometry and closure of the temporary ileostomy.

Bibliography

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Better Outcomes Than Those With Early Onset Disease. Clinical Gastroenterology and Hepatology.
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Colitis. Inflammatory Bowel Diseases. 2013;:1.

4. Ford A, Moayyedi P, Hanauer S. Ulcerative colitis. BMJ. 2013;346(feb05 2):f432-f432.

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