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PubMed2000

The importance of early surgery in children with ulcerative colitis.

BACKGROUND: Ulcerative colitis begins in early childhood in 4% of cases. Medical therapy is non-specific, and as many as 70% of children will ultimately require surgery. The dynamic growth, physical and psychological changes that characterize childhood are severely compromised by the complications of ulcerative colitis and its therapy. OBJECTIVE: To review the outcome of children undergoing early surgery for ulcerative colitis at a tertiary medical center in Israel. METHODS: A retrospective review was conducted of all children operated on following failure of medical therapy for ulcerative colitis during a 5 year period. RESULTS: Eleven children underwent a J-pouch procedure with ileo-anal anastomosis in one to three stages. Postoperative complications included recurrent pouchitis in 5 patients, intestinal obstruction in 3, fistula with incontinence in one, stricture in one, and wound infection in 4. Follow-up revealed that most of the patients have three to four soft bowel movements daily. All currently enjoy normal physical activities and a rich social life. CONCLUSIONS: The quality of life in children with ulcerative colitis was markedly improved following J-pouch surgery. This procedure was not associated with major complications. We recommend early surgery as an alternative to aggressive medical therapy in children with this disease.

Adolescent↗
PubMed2000

The final diagnosis in pouch patients for presumed ulcerative colitis may change to Crohn's disease: patients should be warned of the consequences.

BACKGROUND: The ileal pouch is usually the procedure of choice in the surgical management of Ulcerative Colitis (UC), but pouch surgery has a high complication and failure rate in Crohn's Disease (CD). METHODS: This study is a review of 222 consecutive patients with an initial diagnosis of UC and 3 with CD, treated by ileal pouch anal anastomosis. RESULTS: Only 3 of 225 patients treated by ileal pouch anal anastomosis had a preoperative diagnosis of CD. At the time of follow-up the diagnosis was 23 CD and 202 UC (median follow-up 118.6 months for CD and 91.3 months for UC). 10 of 23 patients with CD had an 1 stage proctocolectomy and pouch and 13 had an initial colectomy. The following were significantly more common in CD than UC: ileo-anal sepsis (30% v 12%: p = 0.028) and pouchitis (65% v 32%: p = 0.0016). The pouch excision rate was 47.8% in CD and 10.9% in UC (p). Uniquely we found that 8/11 patients with CD had perineal sinus after pouch excision compared with only 1/22 in those with UC (p). The median functional score (scale 0-12), in those with intact pouches, was the same in CD and UC: 4 and 3 respectively. CONCLUSION: Our findings show that ileal pouch anal anastomosis is a satisfactory procedure for UC but that the diagnosis had to be changed to CD in 20 of 222 cases. Thus patients should be warned about a 48% failure rate and a high incidence of complications if CD declares itself during follow-up but Crohn's patients who retain their pouch have functional results that are indistinguishable from UC.

Adolescent↗
PubMedDate not supplied

Crohn's disease, ulcerative colitis or indeterminate colitis--how important is it to differentiate?

In most patients coming to the general practitioner or specialist with a history of bloody diarrhoea, bacteria or drugs are the most likely causative agents and it will be possible to make a diagnosis fairly easily. Because of differences in treatment, ulcerative colitis (UC) and Crohn's disease (CD) must however seriously be considered especially in younger patients, with severe symptoms and whenever the history is prolonged. A variety of colitides may indeed be clinically confused with UC and CD. Pathological mimics that should not be missed include infectious diseases such as Campylobacter colitis, yersiniosis, amoebiasis and others; drug-induced diseases (due to nonsteroidal antiinflammatory drugs...); diverticular disease-associated colitis; intestinal endometriosis; intestinal vasculitis and Behçet's disease and iatrogenic conditions such as graft-versus-host-disease and radiation colitis. In most situations a precise diagnosis of these conditions should be possible when all data are available. The term "indeterminate colitis" is used, when a diagnosis of chronic idiopathic inflammatory bowel disease (IBD) is suggested, but the differential diagnosis between UC and CD can not be solved. This occurs in approximately 5% of all patients with IBD. Diagnostic problems can occur in acute fulminant colitis, acute prolonged colitis, chronic relapsing disease and pouchitis. Indeterminate colitis is essentially a temporary diagnosis. Surgical and medical treatment of these patients can be difficult. When surgical treatment is indicated, the type of surgery must be seriously considered. The clinical course of patients with indeterminate colitis is usually more severe when compared with classical UC and these patients require often more severe medical treatment. Diagnostic problems can also arise in longstanding IBD, either UC and CD. Relapse of symptoms can be due to intercurrent infection (CMV is one of the candidates). Medical treatment can influence the microscopic features and induce a discontinuous inflammation in UC, reminiscent of CD. In cases of doubt, the original biopsies should be reviewed to ascertain the diagnosis, and orient treatment.

Colitis↗
PubMed2001

[Therapeutic principles for chronic inflammatory bowel disease].

Whereas the incidence of ulcerative colitis has remained stable at around 8-9/10(5), the incidence of Crohn's disease has increased from below 1 to more than 5/10(5) per year during the last three decades. The new disease entities, collagenous colitis and lymphocytic colitis, are now covered by the term, chronic inflammatory bowel disease. The general principles of treatment of these diseases are to induce remission of outbreaks and to prevent outbreaks during remission. Available pharmaceutical products are 5-aminosalicylic acid preparations, with different delivery profiles in the gastrointestinal tract, glucocorticoids, and other immunosuppressants, especially azathioprine. New immunomodulating agents, with a specific effect on intracellular processes in the inflammatory cascade are now being developed, and infliximab, a TNF-alpha antibody, is now an accepted agent for use in severe, treatment-resistant cases of fistulising Crohn's disease. When medical treatment fails, surgical treatment is an option. In ulcerative colitis, colectomy is, in principle, curative, but it leaves the patient with either a permanent ileostomy or an ileal pouch, which serves as an artificial rectum after ileoanal anastomosis. This latter procedure has the obvious advantage of giving the patient a normal bowel continuity, but complications in the form of intractable "pouchitis" have been experienced in a small number of patients, thus necessitating removal of the pouch. Patients with Crohn's disease, who do not respond to medical treatment or present signs of stenosis in either the small or the large bowel, must be given surgical treatment, although an operation is less curative than in ulcerative colitis. Surgical resections for Crohn's disease must therefore be more conservative, so as to preserve the bowel and only remove macroscopically affected tissue.

Adjuvants, Immunologic↗
PubMed2002

Restorative proctocolectomy: one surgeon's experience of a now routine procedure in a district general hospital.

Restorative proctocolectomy is now the operation of choice for the definitive management of ulcerative colitis and familial adenomatous polyposis coli. The aim of this review is to evaluate clinical and functional results of the first fifty patients treated with restorative proctocolectomy over a period of seven years. A total of 50 patients (28 males, 22 females) underwent restorative proctocolectomy over a period of seven years in our district general hospital. A retrospective analysis of hospital notes was undertaken and supplemented with a patient questionnaire. Forty-three patients had ulcerative colitis and seven had familial adenomatous polyposis coli. Two pouch designs were used, a four limbed "pear pouch" (94%) and a two limb "J" pouch (6%). The majority (98%) of patients had a stapled ileal pouch-anal anastomosis and a similar number had a defunctioning ileostomy. There was no mortality. Early complications (within 30 days of operation) occurred in 18(36%) patients. Late complications were seen in 22 (44%) patients. The median number of daily bowel movements was four (range 1-10). Pouchitis was seen in ten patients (20%). Restorative proctocolectomy is a safe procedure for patients with ulcerative colitis and familial adenomatous polyposis coli. Although total morbidity is appreciable, functional results are generally good and patient satisfaction is high.

Adenomatous Polyposis Coli↗
PubMed2001

Restorative proctocolectomy in UK servicemen.

OBJECTIVE: To investigate the outcome of restorative proctocolectomy (RPC) in UK Servicemen and to determine the compatibility of this procedure with Service life. PATIENTS: All Servicemen undergoing restorative proctocolectomy for ulcerative colitis (UC) or familial adenomatous polyposis (FAP) up to December 31st 2000 were identified from Service records. Patients were reviewed by direct or telephone interview. Pouch function, military duties, medical category or reasons for discharge from the Service were recorded. RESULTS: Fifteen Servicemen (6 Royal Navy, 6 Army, 3 RAF), mean age 30 years, underwent RPC for UC (14) or FAP (1) with a median follow-up of 74 months. Eight remain in their Service, five of whom carry out full duties and three restricted duties. Of the seven who have left the Services only one was medically unfit to continue due to poor pouch function whilst six left voluntarily to pursue active civilian careers. Fourteen patients have acceptable pouch function; one pouch has been excised for intractable pouchitis. CONCLUSIONS: Restorative proctocolectomy is compatible with Service life and most individuals are capable of fulfilling active unrestricted military duties.

Adenomatous Polyposis Coli↗
PubMed2002

[Therapy of inflammatory bowel disease].

The term inflammatory bowel disease (IBD) represents different phenotypes of the idiopathic chronic inflammatory disease of gastrointestinal tract. Until now, ulcerative colitis, Crohns disease, indeterminate colitis and pouchitis were described. Treatment of these diseases is very complex with simultaneous need for individuality. Well-planned treatment requires answers on few questions for every treated: 1. What is the phenotype of IBD? 2. How extended is disease? 3. How active is disease? 4. What is the clinical course of disease until now? Answers on these questions should give complex patient evaluation according to wide accepted IBD protocol including activity estimation with one of activity disease indexes.

Colitis, Ulcerative↗
PubMedDate not supplied

[Probiotics: history, definition, requirements and possible therapeutic applications].

The ingestion of probiotics is associated with various beneficial effects on human health and modifies the physiological homeostasis of the intestinal flora. Probiotics are microorganisms with some particular characteristics: human origin, safety in human use, bile and acid resistance, survival in the intestine, at least temporary colonization of the human gut, adhesion to the mucosa and bacteriocine production. Thanks to these characteristics, probiotics block the invasion of human intestinal cells by the enteroinvasive bacteria. Furthermore, they should be able to stimulate and modulate the intestinal immune response, and to protect and stabilize the mucosal barrier. Finally, the efficacy of probiotics should be evident and documented with valid studies. All their properties should be maintained during processing and storage. Probiotics are usually used to protect the host from pathogens. With regard to this, they are useful in the prevention of antibiotic and traveler's diarrhea and they may play a role in the management of gastric Helicobacter pylori infection. Furthermore, their efficacy in the treatment of infectious diarrhea, in inflammatory bowel diseases, in pouchitis and in food allergy has been shown. Probiotics can improve the symptoms of irritable bowel syndrome and of lactose malabsorption. Finally, it has been suggested that such microorganisms may play a role in the prevention of carcinogenesis and of tumor growth.

Adult↗
PubMedDate not supplied

[Clinical and functional results after restorative proctocolectomy with ileal J reservoir in the treatment of ulcerative colitis].

PURPOSE: Restorative proctocolectomy is the procedure of choice in the treatment of ulcerative colitis. The operation is successful in removing all diseased mucosa while preserving a normal bowel function and a good quality of life for the patient. In this article are presented the clinical and functional results obtained in 28 patients, 19 males (68%) and 9 females (32%) after stapled restorative proctocolectomy with ileal J pouch-anal anastomosis. RESULTS: There were no perioperative deaths. The overall morbidity rate was 31%. Six patients (21%) presented pelvic abscess; 2 (7%) pelvic hematoma, 4 patients (14%) ileo-anal anastomotic stricture, 1 patient (3.6%) pouch-vagina fistula, three patients (11%) intestinal obstruction and 7 (25%) pouchitis. All patients were able to evacuate their pouches spontaneously. The mean bowel movements were 6-9/24 hours at the first postoperative month and 3-5/24 hours at the sixth month. Infrequent nocturnal seepage occurred in 6 patients (21%). Stool consistency returned to normal within 3-6 months. The mean pouch capacity was 210 cc. The mean resting pressure was diminished in 11 patients (39%), the men and maximal squeeze pressures were improved in 9 (32%); the ileo-rectal-anal inhibitory reflex was normal in 5 patients (18%), not defined in 12 (43%). Impotence or impaired bladder function was not present. CONCLUSION: The use of staplers in the surgical technique of restorative proctocolectomy with J shaped ileo-anal pouch is associated with low morbidity and better long-term results. The procedure requires a good selection of patients, a correct surgical timing, a very carefully technique and a low pre and postoperative treatment with steroids.

Adult↗
PubMedDate not supplied

[Quality of life after ileo-anal anastomosis].

BACKGROUND: The ileo-anal pouch is the surgical procedure of choice for patients with Ulcerative Colitis or Familial Adenomatous Polyposis, but has functional limitations such as a higher frequency of bowel movements, anal leakage, and sometimes the necessity of a protective anal pad. OBJECTIVE: To analyze the functional results and quality of life after the pelvic pouch. MATERIAL AND METHODS: This is a descriptive, prolective, and cross-sectional study that analyzes the clinical variables, functional results and self-reported quality of life of patients after an ileo-anal pouch. A correlation between postoperative clinical variables and quality of life was searched. RESULTS: Twenty-seven patients were included. Mean age was 36 years. Surgical indications for the ileo-anal pouch were Ulcerative Colitis in 17 (63%), Familial Adenomatous Polyposis in 9 (33%) and a colo-rectostomy stricture in 1 (4%). Mean number of bowel movements was 4 at day and 1 at night. Eighteen percent of patients referred anal leakage, 11% had pouchitis, and 11% small bowel obstruction. Most of the patients reported high scores in all evaluated quality of life scales. There was a correlation between lower scores of quality of life and a higher number of bowel movements. CONCLUSIONS: The majority of patients reported an adequate quality of life after the ileo-anal pouch; there was a correlation between lower scores of quality of life and a higher number of bowel movements.

Adenomatous Polyposis Coli↗
PubMedDate not supplied

Functional outcome and patient satisfaction after ileal pouch anal anastomosis for ulcerative colitis in a developing country.

AIM: To study the long-term outcome and patient satisfaction of patients with an ileal pouch-anal anastomosis (IPAA) for ulcerative colitis in India. PATIENTS AND METHODS: We studied 35 patients who had undergone IPAA for ulcerative colitis between 1985 and 1998 and had intestinal continuity restored for more than 6 months. These patients were asked to answer a detailed questionnaire on their bowel function, urogenital function, etc. A complete haemogram, serum iron studies, liver function tests and D-Xylose absorption test were done. In addition hepatobiliary ultrasound, stool microscopy, pouchoscopy and pouch biopsies were also performed. Patient satisfaction after the procedure was also evaluated. RESULTS: Thirty-five patients (17 men and 18 women) underwent a complete evaluation. The duration after restoration of continuity ranged from 6 months to 164 months (mean 78.6 months). The mean stool frequency was 7.2 stools per 24 hours. Five patients had urgency of stool, 9 had occasional soiling and 1 had major incontinence. Four patients had minimal restriction of social activities and 1 discontinued his employment. All patients were sexually satisfied except one man who had impotence and one woman who had dyspareunia. Fifteen patients had abnormal serum iron studies (Haemoglobin < 9 g/dl in 11). Eleven patients had D-Xylose absorption below normal values. Two patients were found to have gallstones. All pouch biopsies showed chronic inflammation and 1 patient had histological evidence of pouchitis. Eighty-five percent of patients reported that they were very satisfied with the procedure. CONCLUSION: Good functional recovery and acceptance of the procedure over the long term suggests that it is a valid procedure to be recommended for patients with ulcerative colitis in India.

Adult↗
PubMedDate not supplied

[Surgical treatment of unspecific chronic ulcerative colitis. A 5-year experience].

BACKGROUND: Treatment of ulcerative colitis depends on clinical stage of disease and have precise surgical indications. The aim of this work was to review surgical indications and present data related to our experience. MATERIAL AND METHODS: Retrospective, descriptive, and transversal study. We reviewed records of all patients who underwent a surgical procedure for ulcerative colitis at our service from March 1996 to March 2001. RESULTS: Twenty two patients, 13 males and nine females, ages range 21 to 72 years. Main indication for surgery was no response to medical treatment (50%). Surgical procedures was subtotal colectomy with ileostomy in one patient, intersphincteric proctocolectomy with ileostomy in four intersphincteric proctectomy with ileostomy in three ileorectalanastomosis in three proctocolectomy with ileoanal "J" pouch in six and proctectomy with ileoanal J pouch in five. We had the following complications: oral candidiasis; phlebitis; eventration; pouchitis, and anal fissure in one patient, respectively, pouch-skin fistula in two patients (9%), and retrograde ejaculation in one of these. Follow-up was for 5 years. CONCLUSIONS: Surgical indications for ulcerative colitis are precise. We recommend early surgical evaluation. Ileoanal pouch is now considered the gold standard for surgical procedure because it eliminates disease, neoplasm development, and permanent extra-colonic manifestations, and restores continence.

Adult↗
PubMed2003

Intestinal bacteria and ulcerative colitis.

Convincing evidence from both animal models and the study of patients with ulcerative colitis (UC) implicates the intestinal microflora in the initiation and maintenance of the inflammatory processes in this condition. Despite this, no specific pathogen has been identified as causal and the disease is widely believed to occur as the result of a genetically determined, but abnormal immune response to commensal bacteria. When compared with healthy people, UC patients have increased levels of mucosal IgG directed against the normal microflora. Studies of mucosal bacterial populations in UC indicate that there may be increased numbers of organisms, but reduced counts of "protective" bacteria such as lactobacilli and bifidobacteria. In animal models of colitis, antibiotics, particularly metronidazole, clindamycin, ciprofloxacin and the combination of vancomycin/impinemem protect against UC, especially if given before the onset of inflammation. These antibiotics target anaerobes and some Gram-positive organisms such as enterococci. However, antibiotic use in more than a dozen randomised control trials has been very disappointing, probably because we do not know which species to target, when to give the antibiotics, for how long and in what combinations. Surprisingly, therefore, there is a consistent benefit in the small number of studies reported of probiotics to manage UC and pouchitis. There is scope for more work in this area focussing on the mucosal microflora, its interactions with the gut immune system, its metabolic properties and the potential ways of modifying it.

Animals↗
PubMed1992

[Direct ileum pouch-anal anastomosis in ulcerative colitis. Technique and complications].

Fourty-nine patients (21 female, 28 male) with ulcerative colitis underwent formation of an J-ileal pouch and construction of a direct stapled pouch-anal anastomosis (IPAA) without rectal cuff. 16 patients had previously undergone surgical interventions. Overall after IPAA 7 patients (14%) experienced 11 major complications. Gastrointestinal complications included hemorrhage in 1 patient, pelvic sepsis and ileus in 3 patients, respectively. Pancreatitis and urinary infection occurred in 2 patients, sexual dysfunction in 3 patients. After closure of the ileostomy 3 patients developed late pouch-vaginal or pouch-vesical fistulas, leading to excision of the pouch. During the long-term follow-up small bowel obstruction developed in 3 patients, pouchitis in another 6 patients. After 3 months 84% of our patients were continent during daytime, 67% during nighttime. 24 months postoperatively these data concerning continence increased to 92% and 83%, respectively. We conclude that direct IPAA is a reliable procedure achieving its purpose in 96%.

Adenomatous Polyposis Coli↗
PubMed1992

[Familial adenomatous polyposis: proctocolectomy with an ileal pouch versus rectal preservation].

UNLABELLED: We assess postoperative complications and functional results of surgery in familial adenomatous polyposis (FAP): Group I (n = 11): restorative proctocolectomy with ileoanal anastomosis (RPIA); Group II (n = 8): colectomy with ileorectal anastomosis (IRA): we also have evaluated the presence of malignancy in the rectum in the latter group. Group I: COMPLICATIONS: pelvic abscess (9.1%); intestinal obstruction (9.1%), both requiring reintervention. There was complete anal continence in 81.8%; only one patient needed catheter drainage of the reservoir (9.1%). There were two cases of pouchitis (16.7%). Group II: One patient suffered anastomotic leakage (12.5%) and another one a leakage of the loop ileostomy closure, with and secondary, abdominal abscess (12.5%). There was no incontinence. In spite of periodic endoscopic surveillance rectal adenocarcinoma appeared in 347 patients with complete follow-up (42.9%). Because of the risk of rectal malignancy with IRA and the good functional results of RPIA we consider the latter as the procedure of choice and also advisable the transformation of IAR into RPIA.

Adenocarcinoma↗
PubMed1992

Restorative proctocolectomy--the pouch operation: good or bad?

Restorative proctocolectomy is now the procedure of choice for patients requiring surgery for ulcerative colitis and some for familial adenomatosis. The indications for operation are being refined, and technically the procedure has been simplified. Although it avoids ileostomy, it does not restore normality. Stool frequency, continence problems, and pouchitis can all spoil a good result. In spite of these shortcomings, it represents a major advance.

Adenomatous Polyposis Coli↗
PubMed1992

[Ileoanal pouch for the treatment of adenomatous polyposis and ulcerative colitis--clinical and functional results].

The results of the first 9 patients with proctocolectomy and ileal pouch operated on between 1983 and 1990 were analysed. This procedure was carried out in 8 patients with adenomatous polyposis. Three of these patients had an associated rectal cancer and one a degenerated sigmoid polyp. One patient had ulcerative colitis and was previously submitted to a colectomy related with perforated fulminant colitis. Three types of pouches were constructed: 3 S, 3 J and 3W, all with a temporary ileostomy. A circular stapler was used in 2 cases for ileoanal anastomosis. Three postoperative complications were observed: two patients with pouchitis during the presence of a diverting ileostomy and an ileal fistula following ileostomy closure, all medically treated. Clinical and functional results were evaluated 1 to 7 years after the procedure. The average daytime stool frequency was 4 with 1 nocturnal. All patients indicated normal continence. One patient had her professional life affected due to the increased number of defecations. Differences in the clinical results of the patients with S, J and W pouches were not statistically different. The functional results expressed as median and range were as follows: resting and pressure 45 cm H2O (20-60), voluntary anal pressure 70 cm H2O (34-120), compliance 3.70 ml/cm H2O (1.14-11.40), maximal tolerated volume (MTV) 320 ml (110-48) and threshold volume 95 ml (40-170). The MTV values of the groups with J and W pouches were 190 ml (180-200) and 370 ml (340-480), respectively (p = 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed2004

[Natural therapy instead of chemistry? Probiotics in gastroenterology].

Probiotics are living microorganisms that upon ingestion exert health benefits. The impact of probiotics on gut flora represents a new and interesting therapeutic approach in a number of diseases of the gastrointestinal tract. According to actual publications and guidelines of medical societies, the clinical relevance of probiotics can be described as follows: (a) In the case of ulcerative colitis, available data demonstrate benefits of probiotic therapy. (b) The available data regarding pouchitis are limited, but the therapeutic effect seems to be excellent. (c) In the case of Crohn's disease, the role of probiotics is not clearly defined, thus the results of new trials have to be awaited before probiotic therapy is recommended. (d) Further indications such as antibiotic-associated diarrhea, acute pancreatitis or irritable bowel syndrome have been reported recently. The results of these clinical trials have been encouraging, but they often included only a small number of patients and therefore a clear-cut assessment seems difficult at the moment.

Clinical Trials as Topic↗