Ulcerative Colitis: Surgical Management [sounds like]
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Surgical Management of Ulcerative Colitis (2021)
Ulcerative Colitis: Surgical Management
Perioperative- Medical Management of Ulcerative Colitis
Benign Disease- A 29-year-old patient with prior history of a total colectomy and end ileostomy for fulminant ulcerative colitis presents with peristomal skin irritation and difficulty with leakage around the stoma. Painful, ulcerated purple nodules with violaceous borders are seen around the stoma site, as shown in the image below. Biopsy of the lesion shows neutrophil infiltration and perivascular lymphocytic infiltration and no infection. What is the best next step in management for this patient?
- A 45-year-old man has an 8-year history of moderate-to-severe chronic ulcerative colitis (UC), managed with biologics and with good symptom control. He has no other notable medical or surgical history. His last colonoscopy was performed 1 year ago, with random biopsies demonstrating low-grade dysplasia. The patient is concerned about the development of colorectal cancer due to his history and is here for surveillance endoscopy. What is the best next step in this patient’s management?
- A 37-year-old man with a history of ulcerative colitis (UC) presents after a recent colonoscopy. Clinically and endoscopically, he has no evidence of active disease. He has been on oral mesalamine and 10 mg of prednisone for 6 months. Attempts to wean prednisone below 10 mg result in symptoms including passing of bloody diarrhea and abdominal pain. Which of the following is the best next step in his management?
- A 21-year-old man with a diagnosis of ulcerative colitis 1 year ago presents to the emergency department with abdominal pain, profuse diarrhea, and bloating. Flexible sigmoidoscopy 3 weeks ago demonstrated Mayo score of 3 for proctocolitis, after which he was started on oral prednisone 40 mg daily. Clostridium difficile testing was negative. He has made no improvement. He has lost 10 lbs in the past 2 weeks. His vital signs on presentation are: temperature 38.7 °C, heart rate 140 beats per minute, blood pressure 80/50 mmHg, and spO2 of 94% on room air. He is uncomfortable and pale with a mildly distended abdomen. His abdominal X-ray is shown below. His laboratory work demonstrates: normal range electrolytes, blood urea nitrogen (BUN) of 25 mg/dL, creatinine 1.1 mg/dL, white blood cell count of 25,000, hemoglobin (Hgb) 8.0 g/dL, hematocrit 24%, and platelet count of 370,000. What is the best next step in his care?
- A 55-year-old man with a history of ulcerative colitis (UC) diagnosed in his early 20s presents with a new diagnosis of distal rectal moderately differentiated adenocarcinoma. Mismatch repair (MMR) protein expression is intact; routine surveillance endoscopy showed a mass starting ~2 cm from the anal verge with all other biopsies negative for dysplasia. Laboratory results reveal unremarkable levels of carcinoembryonic antigen (CEA), comprehensive metabolic panel (CMP), and complete blood count (CBC). Systemic staging is negative for metastatic disease. Local staging with magnetic resonance imaging (MRI) reveals a T3N1 lesion. Based on a multidisciplinary tumor board discussion, the patient is planned for total neoadjuvant chemotherapy with upfront chemoradiation followed by consolidation chemotherapy. After this therapy is completed, what is the optimal surgical course for this patient?
- A 22-year-old woman with medically refractory ulcerative colitis presents for consideration of total abdominal proctocolectomy with ileal pouch-anal anastomosis (IPAA). Which of the following should be part of her preoperative evaluation?
- A 48-year-old man with a history of ulcerative colitis (UC) underwent the closure of a diverting ileostomy following an open restorative proctocolectomy with the creation of a J-pouch. Three weeks following stoma closure, he develops enteric drainage from his midline surgical-site, and computed tomography (CT) demonstrates a fistula tract from the tip of the J pouch. This drainage persists after an additional 4 weeks of observation. What is the most appropriate next step in management for this patient?
- A 65-year-old male patient with chronic cirrhosis due to primary sclerosing cholangitis underwent a subtotal colectomy and end ileostomy for refractory ulcerative colitis (UC) 2 years ago. He presents to the emergency department for uncontrolled bleeding from his ileostomy at the mucocutaneous junction. What is the best definitive treatment for this bleeding?
- A 50-year-old man with a 15-year history of ulcerative colitis (UC) is undergoing a surveillance colonoscopy. You find mild active colitis from the rectum to the splenic flexure, normal colon proximally, and a small 5-mm inflammatory polyp in the sigmoid colon. What is the recommended next step to take at this time?
- A 24-year-old man with history of ulcerative colitis (UC) is 3 days status postemergent subtotal colectomy with end ileostomy for toxic megacolon. He has a low-grade fever of 38.0 °C, rising heart rate to the 110s, rising leukocytosis to 15 x 109, and lower pelvic pain and pressure. Computed tomography (CT) of the abdomen and pelvis demonstrates abscess with fluid and gas adjacent and superior to the rectal stump staple line. How could the chance of complication have been reduced?
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- Benign Disease
- A 47-year-old male patient with a history of ulcerative colitis, who is currently taking vedolizumab, presents for routine screening colonoscopy. He has mild proctosigmoiditis, and a 5-mm semipedunculated polyp is noted in the sigmoid colon. What is the best management approach for this polyp?
- A patient with ulcerative colitis refractory to medical therapy undergoes total proctocolectomy. Which extraintestinal manifestation is most likely to persist after the colectomy?
- A 28-year-old man with a history of ulcerative colitis undergoes a total proctocolectomy with stapled ileal pouch–anal anastomosis. Six months after surgery, he presents with urgency, increased stool frequency, and bloody bowel movements. Endoscopic examination findings are shown (Figure A and B). What is the best next step in management?
- A 37-year-old man with a history of ulcerative colitis treated with infliximab and azathioprine is admitted to the hospital with abdominal distention, pain, and a fever of 98.6°F (37°C). After 24 hours of intravenous (IV) methylprednisolone, IV levofloxacin and metronidazole, bowel rest, and resuscitation, his heart rate has increased to 120 beats/min and his temperature is 102.2°F (39°C). Urgent computed tomography reveals megacolon without perforation. The best next step in management is:
- A 55-year-old woman presents to your office for surgical consultation. Colonoscopy had demonstrated hundreds of adenomas carpeting the colon and 30 polyps in the rectum. She has never had a problem with fecal incontinence. What is the best next step in management?
- A 54-year-old woman with a 22-year history of ulcerative colitis undergoes screening colonoscopy. Results of all previous colonoscopies have been negative for dysplasia. In the ascending colon, a flat polyp is resected. Pathology reveals low-grade dysplasia in a background of quiescent (inactive) colitis. What is the most appropriate next step in management?
- A 50-year-old man who underwent a restorative total proctocolectomy with an S-pouch 20 years ago for ulcerative colitis presents with a 2-year history of progressively worsening severe difficulty with evacuation, bloating, and a constant feeling of incomplete evacuation. A flexible pouchoscopy reveals a patent pouch-anal anastomosis with a 7-cm angulated efferent limb to a normal-appearing pouch. These findings are confirmed on a contrast pouchogram. Defecography demonstrates normal pelvic floor relaxation with contrast retained in the pouch despite maximum straining. What is the most appropriate treatment option?
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