Ulcerative colitis
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Ulcerative Colitis (UC)
Definition and Pathology
Ulcerative colitis is a chronic, relapsing inflammatory bowel disease (IBD) confined to the colon and rectum. Unlike Crohn disease, it never affects the small bowel (the "backwash ileitis" sometimes noted at the terminal ileum is a spillover effect, not true disease), it has no skip lesions (inflammation is continuous), and it is limited to the mucosa and submucosa - not transmural.
The disease invariably starts in the rectum and extends proximally in a continuous fashion:
- Proctitis: rectum only
- Proctosigmoiditis: rectum + sigmoid
- Left-sided colitis: up to the splenic flexure
- Pancolitis: entire colon
Macroscopic & Histologic Features
| Stage | Macroscopic | Histology |
|---|---|---|
| Early/mild | Granular, hyperemic, edematous mucosa; loss of vascular pattern | Epithelial necrosis, acute inflammatory infiltrate, cryptitis and crypt abscesses |
| Moderate | Friable mucosa, bleeds on touch | As above + more extensive |
| Severe | Frank ulceration | Crypt abscess, mucosal destruction |
| Chronic | Loss of fold pattern, shortened/narrowed colon, pseudopolyps (epithelial regeneration markers) | Lymphocytic infiltrate + crypt architectural distortion |
Epidemiology
- Peak onset age 20-40 years, with a smaller second peak beyond age 70
- Equal sex distribution (F:M = 1:1)
- Higher incidence in developed countries, urban populations, and those of Ashkenazi Jewish ancestry
Clinical Features
Symptoms:
- Bloody diarrhea (cardinal feature), often with mucus
- Tenesmus and urgency
- Abdominal cramping/pain
- Weight loss, fatigue, fever in moderate-severe disease
- Nocturnal stools
Distinguishing from Crohn disease (Goldman-Cecil, Table 127-1):
| Feature | Ulcerative Colitis | Crohn Disease |
|---|---|---|
| Location | Colon only | Esophagus to anus |
| Pattern | Continuous, from rectum | Skip lesions |
| Inflammation | Mucosal/submucosal | Transmural |
| Fistulae | No | Yes |
| Strictures | No | Yes |
| Perianal disease | No | Yes |
| Ulceration | Continuous | Usually discrete |
Extraintestinal Manifestations
The most common are:
- Inflammatory arthropathies - peripheral (correlates with bowel activity) and axial (ankylosing spondylitis, independent)
- Primary sclerosing cholangitis (PSC) - highest risk in pancolitis; also raises colorectal cancer risk
Others: uveitis/episcleritis (eyes), erythema nodosum/pyoderma gangrenosum (skin), osteoporosis
Diagnosis
Endoscopy (gold standard)
Diffuse mucosal erythema starting at the rectum, extending proximally without skip areas. Severe disease shows ulceration and easy contact bleeding. Pseudopolyps indicate long-standing disease.
Histopathology
Key features: crypt distortion, continuous mucosal inflammation from rectum, absence of granulomas, absence of small bowel involvement.
Laboratory Findings
- CBC: Anemia (iron deficiency from blood loss, B12/folate deficiency in severe/long-standing cases), mild leukocytosis
- ESR, CRP: Elevated with active disease
- Fecal calprotectin: Elevated in active disease, falls with remission - useful monitoring tool
- Hypoalbuminemia: Reflects malnutrition/severity
- pANCA: Present in ~55% of UC patients (vs. ~20% of Crohn patients)
- ASCA: Positive in 40-70% of Crohn, <15% of UC
Serologic Pattern
ASCA-negative + pANCA-positive = favors UC
Disease Activity Severity
| Severity | Features |
|---|---|
| Mild | <4 stools/day, no systemic upset, normal ESR |
| Moderate | 4-6 stools/day, minimal systemic signs |
| Severe | >6 bloody stools/day, fever >37.5°C, tachycardia, anemia, ESR >30 |
| Fulminant | >10 stools/day, continuous bleeding, toxic signs |
Treatment
Mild-Moderate Disease
Aminosalicylates (5-ASA) - first line:
- Mesalazine/sulfasalazine are the mainstay
- Topical (suppository or enema) + oral 5-ASA is superior to oral alone
- Proctitis: mesalazine suppositories ≥500 mg/day PR
- Proctosigmoiditis: mesalazine enemas (reach splenic flexure)
- Left-sided/pancolitis: oral mesalazine ≥3 g/day + topical rectal mesalazine
- Monitor renal function (5-ASA nephrotoxicity)
Corticosteroids (if 5-ASA fails):
- Budesonide (colonic-release formulations): preferred to limit systemic steroid exposure; also available as rectal enema/foam for proctitis/proctosigmoiditis
- Systemic prednisone 0.5-1 mg/kg/day PO if budesonide fails; taper once remission achieved - NOT for maintenance
Moderate-Severe Disease
| Drug | Role |
|---|---|
| IV corticosteroids | First-line for hospitalized severe flares |
| Infliximab (anti-TNF, 5 mg/kg at 0, 2, 6 wk then q8wk) | Rescue therapy; preferred over cyclosporine for ease and safety |
| Cyclosporine 2-4 mg/kg IV | Older rescue option; significant toxicity (nephrotoxicity, myelosuppression, risk of opportunistic infections including PCP) |
| Azathioprine 2 mg/kg/day | Immunomodulator for maintenance; can combine with infliximab |
| Vedolizumab | Gut-selective anti-integrin; approved for moderate-severe UC resistant to steroids, immunomodulators, or anti-TNF |
Recent addition (2025): Guselkumab (anti-IL-23) demonstrated efficacy in Phase 3 trials (QUASAR) for moderately-to-severely active UC - Lancet 2025.
Inpatient management:
- IV steroids + bowel rest + IV fluids
- Antibiotics if severe disease or immunosuppressive use
- Avoid: anticholinergics, antidiarrheal agents, opiates (risk of toxic megacolon)
- Early surgical consultation for all hospitalized UC patients
Maintenance
- 5-ASA agents for most patients
- Azathioprine for steroid-dependent/refractory cases
- Lifelong maintenance reduces relapse risk and colorectal cancer risk
Complications
Toxic Megacolon
Pathologic colonic dilation due to transmural inflammation paralyzing smooth muscle, leading to dilation and perforation. Hallmark: colonic dilation in a systemically toxic patient.
Triggers: anticholinergics, antidiarrheals, narcotics, antidepressants, or recent colonoscopy/barium enema.
Management: bowel decompression, IV steroids, antibiotics, surgical consult - emergency colectomy if no improvement.
Colorectal Cancer (CRC)
- Risk increases with disease duration, extent (pancolitis > left-sided), and concurrent PSC
- Surveillance colonoscopy recommended starting 8-10 years after diagnosis, every 1-2 years
- Dysplasia detection is the key screening goal
Surgery
Colectomy is curative for UC (unlike Crohn disease). Emergency colectomy is required for toxic megacolon or fulminant disease not responding to medical therapy.
Colectomy rates (with modern biologic therapy): ~3% at 1 year, ~7% at 5 years, ~10% at 10 years.
Standard procedure: Total proctocolectomy
- With Brooke (end) ileostomy, OR
- Ileal pouch-anal anastomosis (IPAA / "J-pouch") - preserves continence; complicated by pouchitis in some patients (treated with metronidazole 500 mg TID or ciprofloxacin 500 mg BID for 2 weeks)
Up to 25% of UC patients eventually require colectomy for uncontrolled disease.
Key Differentials
| Feature | UC | Crohn | Infectious Colitis | IBS |
|---|---|---|---|---|
| Blood | Always | Sometimes | Sometimes | Never |
| Pattern | Continuous from rectum | Skip lesions | Variable | No mucosal change |
| Granulomas | No | Yes (50%) | No | No |
| Fistulae | No | Yes | No | No |
Sources: Goldman-Cecil Medicine (26th ed.), Rosen's Emergency Medicine (10th ed.), Rosen's Emergency Medicine - Rosen's Emergency Medicine Concepts and Clinical Practice
Is ulcerative colitis curable
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Is Ulcerative Colitis Curable?
Surgically: Yes. Medically: No.
Surgical Cure
Total proctocolectomy (removal of the entire colon and rectum) is a definitive cure for UC. This works because UC is strictly confined to the colorectum - once all that tissue is removed, the disease cannot recur.
As Maingot's Abdominal Operations states directly: "the only definitively curative treatment of chronic ulcerative colitis is total proctocolectomy."
Goldman-Cecil Medicine confirms: "For ulcerative colitis, colectomy is a curative procedure."
Surgical options include:
| Procedure | Notes |
|---|---|
| Total proctocolectomy + end ileostomy (Brooke ileostomy) | Most definitive; permanent stoma |
| Restorative proctocolectomy + ileal pouch-anal anastomosis (IPAA / J-pouch) | Preferred when feasible; preserves continence; risk of pouchitis (~30-50%) |
| Subtotal colectomy + ileostomy | Used in emergency/fulminant settings; rectum left in place temporarily |
Who needs surgery?
- Toxic megacolon or fulminant colitis not responding to medical therapy
- Refractory disease despite biologics
- Colorectal dysplasia or cancer
- Unacceptable side effects from long-term medical therapy
With modern biologic therapy, the need for surgery has dropped significantly: ~3% at 1 year, ~7% at 5 years, ~10% at 10 years. Up to 25% of patients eventually require colectomy over a lifetime.
Why Medical Therapy Is Not a Cure
Medical treatment - aminosalicylates (5-ASA), corticosteroids, immunomodulators (azathioprine), biologics (infliximab, vedolizumab, guselkumab) - can:
- Induce and maintain remission
- Reduce flare frequency and severity
- Prevent complications (cancer, colectomy)
But they do not eliminate the disease. Once medications are stopped, most patients relapse. The disease persists lifelong, requiring ongoing treatment.
Key Contrast with Crohn Disease
| UC | Crohn Disease | |
|---|---|---|
| Surgically curable? | Yes - proctocolectomy is curative | No - disease recurs in remaining bowel |
| Disease extent | Colon only | Entire GI tract (mouth to anus) |
| Surgery goal | Cure | Palliation/complication management |
This difference is fundamental: because UC is limited to the colon and rectum, removing that organ removes the disease entirely. Crohn disease, by contrast, can involve any part of the GI tract, so surgery manages complications but does not cure it.
Bottom line: UC is the only form of IBD that is surgically curable. For patients with severe, refractory, or complicated disease, surgery offers a genuine cure - not just disease control.
- Goldman-Cecil Medicine (26th ed.), p. 1818
- Maingot's Abdominal Operations, Historical Perspective
- Le Berre C et al., Lancet 2023 - comprehensive review of UC management
Is mild to moderate ulcerative colitis curable
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Is Mild to Moderate UC Curable?
No - not with medical treatment. The same answer applies regardless of severity: medicine controls the disease, surgery cures it. For mild-moderate UC specifically, surgery is almost never warranted, so in practical terms, the goal of treatment is long-term remission, not cure.
What "Remission" Means vs. "Cure"
| Term | Meaning |
|---|---|
| Remission | Symptoms resolved, inflammation suppressed - but the disease is still present and will return if treatment stops |
| Mucosal healing | Endoscopically normal-looking lining - a higher treatment target, associated with better long-term outcomes |
| Cure | Disease permanently eliminated - only achievable with proctocolectomy |
Mild-moderate UC can reach remission and even mucosal healing on medical therapy, but stopping treatment almost always brings the disease back.
The Evidence: What Happens When You Stop Treatment?
A 2026 systematic review and meta-analysis (Arzivian et al., Inflamm Bowel Dis 2026, 29 studies, n=7203) found:
- Stopping oral 5-ASA monotherapy → 60% increased risk of relapse (RR 1.60; 95% CI 1.25-2.05)
- Stopping rectal 5-ASA → double the risk of relapse (RR 2.03; 95% CI 1.58-2.61)
This directly proves that even patients who achieve full remission on 5-ASA are not cured - the disease recurs when treatment is withdrawn.
The only exception noted: patients on immunomodulators or biologics who also take 5-ASA may be able to discontinue the 5-ASA without relapse - but they remain on the other therapy, so the underlying disease is still being suppressed, not cured.
What Medical Treatment Actually Achieves in Mild-Moderate UC
First-line: 5-ASA (mesalazine/sulfasalazine)
- Induces remission in mild-moderate UC
- Maintains remission long-term
- Reduces colorectal cancer risk with continuous use
- Must be taken indefinitely - it is suppressive, not curative
From Goodman & Gilman's Pharmacological Basis of Therapeutics: "Mesalamine (5-ASA): Induction and maintenance of remission in mild-to-moderate ulcerative colitis."
From Katzung's Basic and Clinical Pharmacology: "5-ASA drugs induce and maintain remission in ulcerative colitis and are considered to be the first-line agents for treatment of mild to moderate active ulcerative colitis."
If 5-ASA fails: Budesonide (topical or systemic corticosteroids) can induce remission, but corticosteroids are never used for maintenance - they do not cure, and chronic use causes serious side effects.
Why Surgery Is Rarely Done for Mild-Moderate UC
Proctocolectomy is a major operation with lifelong consequences (permanent ileostomy or risk of pouchitis with a J-pouch). For mild-moderate disease that is well-controlled on 5-ASA, the risks of surgery far outweigh the benefits of a "cure." Surgery is reserved for:
- Severe/refractory disease not responding to biologics
- Toxic megacolon or perforation
- Colorectal dysplasia or cancer
- Unacceptable drug toxicity
Bottom Line
| Mild-Moderate UC | |
|---|---|
| Medically curable? | No |
| Goal of medical treatment | Remission + mucosal healing |
| Can treatment be stopped? | No - stopping 5-ASA doubles relapse risk |
| Surgically curable? | Yes - but rarely indicated at this severity |
| Natural course without treatment | Chronic relapsing-remitting; risk of progression |
Mild-moderate UC is a lifelong condition managed with continuous treatment. The distinction between mild and severe UC affects which drugs are used and how urgently, but not the fundamental answer about curability.
Proctocolectomy
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Proctocolectomy
Definition
Proctocolectomy is the surgical removal of the entire colon and rectum. When combined with removal of the anus it is called a total proctocolectomy. It is the definitive curative operation for ulcerative colitis, and is also performed for familial adenomatous polyposis (FAP) and selected colorectal cancers.
As Maingot's Abdominal Operations states: "The intestinal component of chronic ulcerative colitis is cured once the colon and rectum are removed."
Indications
Emergency (Urgent Surgery Required)
- Toxic megacolon failing medical therapy
- Fulminant colitis not improving within 24-48 hours of aggressive medical management
- Massive life-threatening hemorrhage
- Free perforation
Elective
- Intractability despite maximal medical therapy (including biologics)
- Complications of chronic steroid use (e.g., aseptic necrosis of joints)
- Colorectal dysplasia or cancer risk - the risk of malignancy is approximately 2% after 10 years, 8% after 20 years, and 18% after 30 years of UC
Types of Proctocolectomy
There are two main surgical options:
1. Total Proctocolectomy with Brooke (End) Ileostomy
The entire colon, rectum, and anus are removed and the terminal ileum is brought to the skin surface as a permanent stoma.
Advantages:
- Often a one-stage procedure
- Disease completely eliminated - no further medical therapy needed
- No risk of colorectal malignancy
- Lower operative complexity
Disadvantages:
- Permanent ileostomy (bag worn externally)
- Psychosocial implications - patients tend to be young and active
- Daily obligatory Na+ losses of 30-40 mEq/day (vs 1-2 mEq/day normal)
- Risk of urolithiasis (~5%) due to altered urinary composition
Who gets this? Preferred in older patients, those with significant comorbidities, low rectal cancers, perianal disease, prior anorectal surgery, or those not suitable for IPAA. Despite preoperative concerns, studies consistently show most patients accept the ileostomy and report high quality of life postoperatively.
2. Restorative Proctocolectomy with Ileal Pouch-Anal Anastomosis (IPAA / "J-Pouch")
The entire colon and rectum are removed, but the anal sphincter muscles are preserved. A reservoir is constructed from the terminal ileum and anastomosed to the anal canal, restoring continence and avoiding a permanent stoma.
Pouch configurations:
| Configuration | Notes |
|---|---|
| J-pouch | Most common - simplest to construct, equivalent functional outcomes |
| S-pouch | Older technique, rarely used now |
| W-pouch | Larger reservoir, more complex construction |
Anastomotic techniques:
| Technique | Description | Pros | Cons |
|---|---|---|---|
| Double-staple | Circular stapler through anal canal; small cuff of rectal mucosa retained (anal transition zone) | Simpler, better functional outcomes | Residual mucosa may develop dysplasia (4.5%) |
| Mucosectomy + hand-sewn | All diseased mucosa removed down to dentate line | Eliminates all at-risk mucosa | Higher risk of incontinence, technically demanding |
Surveillance: Annual digital rectal exam and anoscopy/proctoscopy of the anastomosis and anal transition zone is recommended regardless of technique.
Surgical Technique Overview (Maingot's / Fischer's)
- Position: Modified lithotomy, buttocks over table edge, anus sutured closed
- Abdominal phase: Midline incision; medial-to-lateral mobilization of colon; inferior mesenteric vessels ligated (low ligation preferred to protect sympathetic nerves)
- Rectal dissection: Posterior plane between fascia propria of rectum and presacral fascia (like total mesorectal excision); careful identification and protection of left ureter, sympathetic and parasympathetic nerves
- Perineal phase: Rectum skeletonized of mesorectum (unlike cancer surgery) to reduce parasympathetic nerve injury risk
- Ileostomy maturation (if applicable): Brooke technique - bowel everted and secured creating a protruding nipple for appliance use
Approach: Can be performed open, laparoscopic, hand-assisted laparoscopic, or robotic. Minimally invasive approaches are associated with less morbidity when compared to open.
Pouchitis - The Key Complication of IPAA
Pouchitis is inflammation of the ileal pouch - the most common long-term complication after restorative proctocolectomy.
Classification
| Type | Description |
|---|---|
| Acute pouchitis | Episodic, responds to antibiotics |
| Chronic antibiotic-dependent | Relapses shortly after stopping antibiotics |
| Chronic antibiotic-refractory | Inadequate response to antibiotics |
| Crohn's-like disease of the pouch | Behaves like Crohn disease in the pouch |
| Cuffitis | Inflammation of the residual rectal cuff at the anastomosis |
Management (AGA 2024 Guidelines - Barnes et al., Gastroenterology 2024)
| Situation | Recommended Treatment |
|---|---|
| Intermittent pouchitis | Antibiotics (metronidazole 500 mg TID or ciprofloxacin 500 mg BID × 2 weeks) |
| Recurrent pouchitis responsive to antibiotics | Probiotics for prevention of recurrence |
| Chronic antibiotic-dependent pouchitis | Chronic antibiotic therapy; or biologics/small molecule drugs if antibiotic-intolerant |
| Chronic antibiotic-refractory pouchitis | Advanced immunosuppressives (biologics); corticosteroids also an option |
| Crohn's-like pouch disease | Corticosteroids + advanced immunosuppressives |
| Cuffitis | Topical mesalamine or topical corticosteroids |
Physiologic Consequences
After proctocolectomy the colon's water and electrolyte absorption function is lost:
- Normal colon absorbs 1000-1500 mL water and 100 mEq NaCl daily
- Brooke ileostomy output: 500-1200 g/day (90% water)
- Obligatory Na+ losses: 30-40 mEq/day (vs 1-2 mEq normal)
- Risk of dehydration and electrolyte imbalance during illness, vomiting, or exercise
- Increased risk of urolithiasis (~5%) - urate and calcium stones
- Chronic oliguria expected even with functioning ileostomy
Key Structure at Risk Intraoperatively
| Structure | Risk |
|---|---|
| Left ureter | Injury during rectal/sigmoid mobilization |
| Sympathetic nerves (L1-L3) | Retrograde ejaculation, bladder dysfunction |
| Parasympathetic nerves (S2-S4/nervi erigentes) | Erectile dysfunction, bladder dysfunction |
| Inferior epigastric vessels | Injury during stoma formation |
Outcomes
- Colectomy rates in UC with modern biologic therapy: ~3% at 1 year, ~7% at 5 years, ~10% at 10 years
- Up to 25% of all UC patients eventually need colectomy over a lifetime
- IPAA provides good quality of life and continence in appropriately selected patients
- Most patients with permanent ileostomy report high quality of life and acceptance of the stoma postoperatively
Sources: Schwartz's Principles of Surgery (11th ed.), Fischer's Mastery of Surgery (8th ed.), Maingot's Abdominal Operations, Sleisenger & Fordtran's Gastrointestinal and Liver Disease, AGA Guideline on Pouchitis 2024
After proctocolectomy how can we defecate
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After Proctocolectomy: How Do You Defecate?
The answer depends entirely on which type of proctocolectomy was performed. There are three options, each with a completely different mechanism of stool elimination.
Option 1: Brooke Ileostomy (Permanent External Bag)
The terminal ileum is brought through the abdominal wall as a stoma. Stool collects continuously in an external pouching appliance (bag) worn on the abdomen.
How it works:
- There is no voluntary control over when stool exits - the ileostomy drains continuously
- The stoma is "spouted" (everted) to direct liquid stool away from the skin into the bag
- The bag is emptied several times daily and changed regularly
- There is no anal defecation - the anus is surgically closed
Stool characteristics:
- Output: 500-1200 g/day (90% water) - liquid to semi-liquid consistency
- The colon is gone, so water is NOT reabsorbed - output is always liquid/semi-formed
- Obligatory sodium losses of 30-40 mEq/day (must be compensated with diet)
- Foods high in fibre increase solid component; antidiarrheal medications (loperamide, psyllium) can thicken output
Who gets this? Older patients, those with poor sphincter function, low rectal cancers, perianal disease, Crohn disease, or those not suitable for IPAA. Despite initial concerns, studies consistently show patients report high quality of life and most accept the ileostomy well postoperatively.
Option 2: IPAA / J-Pouch (Anal Defecation - Most Common)
This is the preferred option for younger patients. The anal sphincter is preserved and a reservoir (pouch) made from the terminal ileum is connected directly to the anal canal. The patient still defecates through the anus.
How it works:
- The J-shaped ileal reservoir acts as a "neo-rectum" - it fills with stool and the patient feels an urge to defecate
- Stool passes voluntarily through the anal canal and sphincter, just as before surgery
- The key difference: ileum absorbs far less water than the colon ever did, so stools are more frequent and looser
Functional outcomes (what to expect):
| Parameter | Typical Result |
|---|---|
| Stool frequency | 4-8 times per 24 hours (including at least one nocturnal evacuation early on) |
| Urgency | Common, especially in first year |
| Minor fecal incontinence | Common initially, improves with time as pouch capacity increases |
| Nocturnal incontinence | Less common with stapled technique |
| Long-term pouch retention | 85-90% of patients keep their IPAA long-term |
From Bailey & Love's: "Stool frequency, urgency and minor faecal incontinence are common, but usually reduce with time as ileal pouch capacity increases. The majority of patients with IPAA have a very good quality of life."
Important note for women: Reduced fertility and vaginal dryness (from denervation of vaginal secretory glands) are recognised risks. Women who have not completed their family may elect for colectomy + ileostomy first, with IPAA deferred.
Option 3: Continent Ileostomy (Kock Pouch) - Rarely Used
A reservoir is constructed from 45 cm of distal ileum with an internal nipple valve that holds stool in. The stoma opens onto the abdomen but is continent - no external bag is worn. The patient intubates (inserts a catheter) through the stoma 3-4 times daily to drain the pouch.
How it works:
- Stool collects in the internal ileal reservoir
- A specially designed intussuscepted nipple valve prevents leakage
- Patient inserts a soft catheter through the flush abdominal stoma several times a day to empty it
- No external bag needed, but requires manual catheterisation each time
Indications (Fischer's):
- Patients with an existing Brooke ileostomy who cannot have IPAA (no anal sphincter) but want to avoid an external bag
- Poor anal sphincter function making IPAA unsuitable
- Failed IPAA (not due to Crohn disease)
Why it's rarely done now: The nipple valve mechanism is technically difficult and prone to prolapse and dysfunction requiring reoperation. IPAA has largely replaced it.
Comparison of All Three Options
| Brooke Ileostomy | IPAA (J-Pouch) | Kock Pouch | |
|---|---|---|---|
| Route of defecation | External bag (stoma) | Anus (normal route) | Catheter through stoma |
| Voluntary control | None | Yes | Yes (via catheter) |
| External appliance | Yes - permanent bag | No | No |
| Stool frequency | Continuous drainage | 4-8×/day | Catheterised 3-4×/day |
| Continence risk | N/A | Minor incontinence common early | Valve failure risk |
| Pouchitis risk | None | Up to 50% | Yes |
| Best for | Elderly, poor sphincter, complex disease | Young, fit, good sphincter | Failed IPAA, no sphincter |
| Curative for UC? | Yes | Yes | Yes |
Why Stool Is Always Loose After Proctocolectomy
Regardless of which option, stool will be more liquid and more frequent than before, because:
- The colon is gone - it normally absorbs 1000-1500 mL of water daily
- The ileum (which forms the reservoir or ileostomy) absorbs far less water
- Over time, the ileum partially adapts and stool may thicken somewhat
- Dietary modification (low-fibre foods thicken output; psyllium, loperamide can help)
Sources: Bailey & Love's Short Practice of Surgery (28th ed.), Sleisenger & Fordtran's GI and Liver Disease, Fischer's Mastery of Surgery (8th ed.), Schwartz's Principles of Surgery (11th ed.)
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