Question:
I have had ulcerative colitis for five years. My doctor has recommended a colectomy and a J pouch. Will I be cured of my colitis and will my symptoms go away completely?

Dr. Sands:
A colectomy is usually recommended in ulcerative colitis when the disease cannot be well controlled with medications, or alternatively in the fortunately rare circumstance of colon cancer or dysplasia (pre-cancerous changes) complicating the disease. For the last 25 years, the J pouch, which is a reservoir constructed of small bowel that sits where the rectum had been, has been a good alternative for those who did not wish to have a stoma (where the small bowel is turned out onto the surface of the abdomen and stool is collected in a bag, or “appliance.”) While either type of surgery provides excellent relief of the symptoms of unremitting colitis, many will prefer a J pouch because of the ability to have continent bowel movements without an external appliance.

Having a colectomy and J pouch will cure ulcerative colitis, which by definition is a disease of the large bowel. However, life with a J pouch is not exactly like life with a normal and healthy large bowel. Because the capacity of the J pouch is smaller than the large bowel, the typical number of bowel movements is 5 to 8 a day. These movements should be well controlled and not urgent. Many patients experience the need for a bowel movement during the night. In addition, people who have a J pouch for ulcerative colitis may experience “pouchitis,” inflammation of the J pouch that is similar to ulcerative colitis itself. This may cause diarrhea, urgent bowel movements, and rarely, incontinence. Episodes of pouchitis usually respond well to antibiotics. However, approximately 5 to 10% of patients may experience chronic pouchitis, which may require long-term treatment.

None of this should persuade you from having a J pouch if you need one. While a J pouch is not quite like having a large bowel it is certainly much better than being sick with colitis.

Question:
I have had Crohn’s disease for eight years and have just had my second surgery (resection and a strictureplasty) Is there a way to prevent my disease from coming back? Will medications work for me?

Dr. Sands:
It is unfortunate but true that 80% of patients with Crohn’s disease need a surgery at least once in their life; many need 2 or more surgeries. Surgeries are most often needed for complications arising from Crohn’s disease, such as an abscess or a bowel obstruction from a stricture (narrowing of the bowel caused by scar tissue). A number of medications have been studied for their ability to prevent disease from coming back. 5-Aminosalicylates (5-ASA drugs) such as mesalamine (Pentasa, Asacol), while safe, appear to offer very little protection from the return of Crohn’s disease. Some antibiotics, including metronidazole, have been shown to delay the return of Crohn’s disease, but unfortunately may not be well tolerated as a long-term treatment. Azathioprine and 6-mercaptopurine, which are immune modulators, may be useful in preventing disease recurrence. Still, not all studies have shown these to be effective. The bottom line is that none of these medications are perfect in keeping Crohn’s disease at bay after surgery. Therefore, it is best to discuss the risks and benefits of these medications with your doctor. Most important, once you embark on a course of treatment, it is wise to follow the disease closely, to assess whether the treatment you have chosen is working.

Question:
I have what my doctor calls proctosigmoiditis for the past 15 years. I have never been very sick nor have I been admitted to a hospital. Am I at risk for colon cancer? What are the risk factors for colon cancer?

Dr. Sands:
Proctosigmoiditis is ulcerative colitis that involves only the rectum and the sigmoid colon, which lies just above the rectum. Studies have indeed shown that people with ulcerative colitis are at increased risk for colon cancer. This risk is related to the length of bowel involved and the time since onset of the disease. That is, the more bowel involved and the longer the time since the disease began, the higher the risk. For people with left sided ulcerative colitis (involving the rectum, sigmoid colon and left colon) the risk of colon cancer is greater than that among people of the same age who do not have colitis, and continues to rise every year starting at 15 years from the onset of the disease. Your disease is not as extensive as the left colon, and therefore you are at somewhat lower risk. Some evidence suggests that people with more inflammation tend to have higher risk. The fact that you have not been very sick over the years suggests that you have less severe inflammation, and may also be at lower risk. In addition, some studies suggest that people diagnosed at a younger age have a higher risk of colon cancer, as do people who also have a family history of colon cancer. Overall, your risk of colon cancer may not be as high as many individuals with ulcerative colitis, but is also likely to be a bit higher than someone who does not have this condition. You should discuss with your doctor whether surveillance colonoscopy and biopsies would be appropriate to reduce your risk of cancer.

Question:
I have just had a flare-up of my ulcerative colitis. I am much better and I am taking a 5ASA drug and prednisone. How long does it take for a moderately severe attack to heal and do I have to continue on medicines even if I now feel better?

Dr. Sands:
It’s great that your flare responded well to prednisone. But you are correct that even when you feel better, it simply takes some time for the lining of your colon to heal. This may take weeks, perhaps as little as 2, or as many as 8, depending on how severe the flare was. Now that your flare is over, it will be your goal to taper off of prednisone, which although useful in quieting down a flare, does nothing to prevent the next flare and yet has many possible side effects. The hope would be that you will remain well while continuing on a 5ASA drug. This may be useful for some patients in maintaining that hard-earned response, and is quite safe. Unfortunately, some individuals will not succeed in tapering off prednisone without having a relapse. Such individuals would likely benefit from starting on azathioprine or 6-mercaptopurine, and staying on these as maintenance medications to prevent a relapse.

Question:
I have Crohn’s disease and just developed a fistula around the rectal area. My Gastroenterologist has asked me to see a colorectal surgeon. Is this the correct approach or are there medicines that treat fistula?

Dr. Sands:
Fistulas are a frequent complication of Crohn’s disease, and occur when the inflammation from inside the bowel penetrates outside the bowel. Most often this occurs around the rectal area (perianal fistula). Fistulas may occur as well between 2 pieces of bowel, between bowel and bladder, bowel to the abdominal wall, and even the vagina. This can be a very difficult and disturbing problem. More than most any other aspect of treating Crohn’s disease, fistulas require a combined medical-surgical approach. The perianal area is very touchy, and it is quite useful for a surgeon to examine a perianal fistula while the patient is under anesthesia. This permits the fistula to be carefully probed to determine its course. In addition, the surgeon may place a “seton,” a piece of thread or elastic that keeps the track from closing over and becoming a painful and infected abscess. Once the seton is in, medications that may help the fistula to close include antibiotics, 6-mercaptopurine, azathioprine and infliximab (Remicade).