Colitis in surgery

1. Surgical classification

2. Clinical features suggesting severe colitis

• Frequent bloody diarrhea, fever, tachycardia
• Severe abdominal pain, distension, guarding, peritonitis
• Dehydration, anemia, electrolyte disturbance, hypoalbuminemia
• Systemic toxicity: hypotension, confusion, renal dysfunction, sepsis
• Increasing abdominal distension or reduced bowel sounds, suggesting toxic megacolon

• CBC, CRP, electrolytes, renal function, liver tests, coagulation profile, blood group and cross-match
• Stool culture and C. difficile assay
• Abdominal X-ray for colonic dilatation
• Contrast CT if perforation, ischemia, abscess, obstruction, or another complication is suspected
• Flexible sigmoidoscopy with limited insufflation when diagnosis is uncertain. Avoid full colonoscopy in fulminant colitis or suspected toxic megacolon.

3. Indications for emergency surgery

1. Free perforation or generalized peritonitis
2. Toxic megacolon, especially with worsening systemic toxicity or impending perforation
3. Massive or ongoing lower GI bleeding with hemodynamic instability
4. Failure of intensive medical treatment in acute severe UC or fulminant C. difficile colitis
5. Transmural ischemia, gangrene, or necrotic bowel in ischemic colitis
6. Sepsis, uncontrolled deterioration, or multiorgan dysfunction
7. In Crohn disease: obstruction from stricture, intra-abdominal abscess, fistula, perforation, or uncontrolled bleeding.

4. Surgical management by cause

A. Acute severe ulcerative colitis

• Admit, resuscitate with IV fluids and correct electrolytes
• IV corticosteroids for acute severe flare
• Thromboprophylaxis, nutritional support, blood transfusion if required
• Serial abdominal exams, stool chart, CRP, X-ray if dilatation suspected
• Early joint management by gastroenterology and colorectal surgery

• Subtotal colectomy with end ileostomy and rectal stump is preferred.
• It is a damage-control operation: removes diseased colon, controls sepsis/bleeding, avoids pelvic dissection in an unstable, malnourished patient.
• Do not perform primary ileal pouch-anal anastomosis (IPAA) in the acute toxic setting.

• Restorative proctocolectomy with IPAA (J-pouch), usually with a temporary loop ileostomy
• Total proctocolectomy with permanent end ileostomy
• Selected cases: ileorectal anastomosis, only if rectum is relatively spared and surveillance is acceptable.

B. Crohn colitis

• Obstruction due to fibrotic stricture
• Perforation, abscess, fistula, phlegmon
• Massive bleeding
• Cancer/dysplasia
• Medically refractory localized disease

• Limited segmental colectomy for localized colonic disease
• Ileocolic resection for ileocaecal disease
• Stricturoplasty for selected small-bowel strictures
• Drainage of abscess, often with antibiotics and selective percutaneous drainage
• Seton drainage for perianal fistula/sepsis
• Subtotal colectomy with ileostomy in severe diffuse colitis when necessary

C. Fulminant Clostridioides difficile colitis

• Start disease-directed antibiotics and aggressive resuscitation.
• Early surgical involvement is essential if shock, peritonitis, megacolon, perforation, or progressive organ failure occurs.
• Standard operation in fulminant disease is usually subtotal colectomy with end ileostomy.
• In carefully selected non-perforated cases, diverting loop ileostomy with antegrade colonic lavage is an alternative in experienced units.

D. Ischemic colitis

• Peritonitis
• Perforation
• Gangrene or transmural necrosis
• Persistent sepsis
• Stricture causing obstruction
• Ongoing bleeding or failed conservative management

5. Toxic megacolon

• Distended tender abdomen
• Fever, tachycardia, hypotension
• Leukocytosis and anemia
• Colonic diameter commonly >6 cm on radiograph
• Altered mental state, electrolyte abnormality, or dehydration

• ICU-level resuscitation and close monitoring
• Nil by mouth, IV fluids, correction of potassium/magnesium
• Avoid opioids, anticholinergics, and antimotility drugs
• Broad-spectrum antibiotics if septic or perforation is suspected
• Treat the underlying colitis
• Immediate surgery for perforation, uncontrolled bleeding, clinical deterioration, or failed rescue treatment

6. Elective surgery in ulcerative colitis

• Medically refractory disease or steroid dependence
• Intolerable medication adverse effects
• High-grade dysplasia or colorectal carcinoma
• Multifocal/invisible dysplasia confirmed by expert pathology
• Chronic poor quality of life despite optimized therapy
• Growth failure in children

Exam summary

In a patient with severe colitis, first identify the cause, resuscitate, exclude perforation and toxic megacolon, involve colorectal surgery early, and operate for perforation, toxic megacolon, uncontrolled hemorrhage, ischemic necrosis, or medical treatment failure. The typical emergency operation for fulminant UC or C. difficile colitis is subtotal colectomy with end ileostomy; Crohn disease requires the most limited bowel-preserving operation feasible.