When is surgery indicated for the treatment of ulcerative colitis (UC)?

Updated: Apr 01, 2019
  • Author: E Stanton Adkins, III, MD; Chief Editor: Harsh Grewal, MD, FACS, FAAP  more...
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Indications for urgent surgery in patients with UC include the following:

  • Toxic megacolon refractory to medical management
  • Fulminant attack refractory to medical management
  • Uncontrolled colonic bleeding
  • Perforation (free or walled off)
  • Obstruction and stricture with suspicion for cancer

Indications for elective surgery in UC include the following [2] :

  • Refractory disease with failure of medical management
  • Chronic steroid dependency
  • Dysplasia or adenocarcinoma found on screening biopsy
  • Disease present for 7-10 years
  • Systemic complications from medications, particularly steroids
  • Failure to thrive, in children

Failure of medical management is the most common indication for surgery. Classically, an acute attack of UC that does not respond to intravenous (IV) steroid therapy within 10 days warrants surgical intervention.3 A study by Saha et al suggested that performing colectomy early (< 7 days) in patients with steroid-refractory acute severe UC could improve operative outcomes. [3]  

Steroid dependency is a predictor for the need for surgery and is likely a marker for more severe disease.

In children, the presence of pancolitis is the strongest predictor of the need for surgery; more than 80% of patients who require surgery have total colonic involvement. [4] However, during a fulminant attack, the patient's condition is compromised, with a potentially poor nutritional status, low albumin level, low hematocrit level, and complications of high-dose corticosteroid use. [5] Cyclosporine therapy may be useful in inducing remission, providing a window to an improvement in the patient's overall health status prior to surgery and, hence, minimizing complications.

Other indications for surgical intervention include hemorrhage, intolerance to steroid therapy, and growth retardation. One major goal of management in children is the avoidance of growth retardation caused by long-term steroid use. [4]

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