Colitis

Ulcerative colitis is a serious illness affecting the colon. It can be managed medically, but surgery is the only definitive way to remove the disease in its entirety. Ulcerative colitis is an inflammatory bowel disease (IBD) that invariably involves the rectum and may involve all or part of the colon but not the small intestine. Although the disease is mild in some patients, ulcerative colitis increases patients' risk of cancer, depending on the duration and extent of the disease.

Ulcerative colitis is a continuous disease extending in a retrograde fashion from the rectum, so there are no intervening normal areas of colon. Ulcerative colitis is in the same category as Crohn's disease, another type of IBD. Crohn's disease may occur as patchy ulcerations in the small or large bowel and can affect the entire gastrointestinal (GI) tract from mouth to anus. The entire bowel wall is affected in Crohn's disease, whereas ulcerative colitis affects only the mucosa (ie, inner lining) of the colon and rectum. indeterminate colitis describes the category of conditions in which distinguishing between Crohn's disease and ulcerative colitis is impossible.

The incidence of ulcerative colitis is eight to 15 people per 100,000 in the United States and Northern Europe. (1) The lowest rate (ie, 0.34 per 100,000) occurs in Japan? The incidence of ulcerative colitis peaks during the third decade of life and again during the seventh decade. (1)

NORMAL BOWEL PHYSIOLOGY

Normal physiological bowel processes promote defecation and normal health and flora of the bowel. These processes include water, sodium, and ammonia absorption; fatty acid, mucous, and gas production; maintenance of colonic bacteria; and motility.

WATER AND SODIUM ABSORPTION. The colon is the major site of water absorption and electrolyte exchange in the body. Approximately 90% of the fluid contained in the ileum (ie, distal portion of the small intestine) is absorbed in the colon. This amounts to 1,000 mL to 2,000 mL per day. The entire colon can absorb up to 5,000 mL of fluid daily. As much as 400 mEq of sodium is actively absorbed. Water absorption occurs passively as it follows the transported sodium. Potassium transport also is passive. Absorption of fluid is not equal throughout the colon. The right colon absorbs more salt and water than the distal colon; thus, a patient undergoing a right hemicolectomy is more likely to have diarrhea than a patient undergoing a left hemicolectomy. (2)

AMMONIA ABSORPTION. Ammonia in the colon is derived, to some extent, from dietary nitrogen, epithelial cells, and bacterial debris. Ammonia absorption depends partially on intraluminal pH. Patients taking broad-spectrum antibiotics have decreased amounts of colonic bacteria, decreased intraluminal pH, or both, which decreases ammonia absorption. This is important for patients with impaired kidney function or liver failure who cannot clear the extra ammonia.

FATTY ACIDS PRODUCTION, The production of short-chain fatty acids provides an important source of energy for the colonic mucosa. Metabolism of these fatty acids by the colonocytes provides energy for processes, such as active sodium transport. Some short-chain fatty acids are produced by bacterial fermentation of dietary carbohydrates. Mucosal atrophy may result when dietary sources of fatty acids are lacking or when the fecal stream is diverted by an ileostomy or colostomy. In patients with such diversions, this is known as diversion colitis.

MUCUS PRODUCTION. Mucus is secreted in the lumen of the colon. The epithelium contains large numbers of mucus-secreting cells. Even if feces are diverted by an ileostomy or colostomy, mucus will continue to be produced and secreted by the distal bowel.

GAS PRODUCTION. Intestinal gas arises from swallowed air, diffusion from the blood, and intraluminal gas production. The major components of gas are nitrogen, oxygen, carbon dioxide, hydrogen, and methane. The GI tract usually contains between 100 mL and 200 mL of gas, and 400 mL to 1,200 mL is released as flatus, depending on the type of food ingested. (1) Nitrogen and oxygen come largely from swallowed air, but carbon dioxide is produced by the reaction of bicarbonate and hydrogen ions. The digestion of triglycerides to fatty acids also produces these ions. Hydrogen and methane gases are produced by colonic bacteria.

COLONIC BACTERIA MAINTENANCE. Approximately 30% of fecal dry weight is bacteria (ie, [10.sup.11] to [10.sup.12] bacteria per gram of feces). (1) The most common bacteria are anaerobes, of which the Bacteroides species predominates. Eschericia coli are the most common aerobes. Endogenous microflora are crucial for carbohydrate and protein breakdown. They also participate in bilirubin, bile acid, estrogen, and cholesterol metabolism. Additionally, colonic bacteria are necessary for vitamin K production and suppression of pathogenic microorganisms (eg, Clostridium difficile). Conversely, a high colonic bacterial load may contribute to sepsis in critically ill patients. In a surgical patient, wound infection can occur after a colectomy procedure.

MOTILITY. Colonic motility can be described as intermittent contractions of either low or high amplitude. Low-amplitude, short-duration contractions occur in bursts that move the contents of the colon both forward and backward. This, in turn, delays colonic transit time, which allows more time for water absorption and electrolyte exchange. High-amplitude contractions occur in a coordinated fashion, creating mass movements of fecal material.

Defecation involves mass colonic movement, an increase in intra-abdominal and rectal pressure, and relaxation of the pelvic floor. As the rectum becomes distended, it causes reflex relaxation of the internal anal sphincter. This allows rectal contents to make contact with the anal canal. Through this sampling reflex, the sensory epithelium distinguishes between solid stool, liquid stool, and gas. Defecation occurs through coordination of increasing intra-abdominal pressure, increased rectal contraction, relaxation of the puborectalis muscle, and opening of the anal canal.

The normal physiology of the colon is adversely affected in patients suffering from ulcerative colitis. This becomes evident as the disease progresses. When the colon is removed, all colonic functions are lost. This in and of itself affects the ability of the patient with ulcerative colitis to adapt postoperatively.

CAUSAL FACTORS OF ULCERATIVE COLITIS

There is no proven etiology for IBD in general nor has one been established for ulcerative colitis specifically. Differences in incidence in various parts of the world suggest that infection or environmental factors, such as diet, may be involved. Smoking, drinking alcohol, and using oral contraceptives have been identified as causal agents. There may be an autoimmune mechanism, a defect in the intestinal immune system, or a combination of both problems. (1) Additionally, genetic factors may play a significant role in determining whether an individual is susceptible to IBD. (3)

CLINICAL COURSE AND DIAGNOSIS

Ulcerative colitis is a dynamic disease with remissions and exacerbations. It involves the colonic mucosa and submucosa, which become infiltrated with inflammatory cells. The mucosa often is quite friable. As the inflammatory process progresses, the colon actually may be foreshortened as mucosa is replaced by scar tissue. Crypt abscesses are common, as are inflammatory pseudopolyps. The outside of the bowel wall usually is not thickened or inflamed.

The rectum invariably is involved (ie, proctitis), although in some cases the entire colon is involved (ie, pancolitis); in others, just parts of it may be involved (eg, proctosigmoiditis) (Figure 1). Unlike Crohn's disease, ulcerative colitis does not involve the small intestine. A few inches of the terminal ileum, however, can be inflamed for a few inches because of backwash from the colon. This is known as backwash ileitis. The key component to diagnosing ulcerative colitis is homogenous involvement of the rectum and colon.

[FIGURE 1 OMITTED]

The degree of a patient's mucosal inflammation determines the severity of his or her symptoms. For some patients, symptoms are insidious and, at the very least, consist of minimally bloody stools. Other patients complain of severe, explosive, bloody diarrhea and cramping abdominal pain. The degree of weight loss, malaise, and anemia depend on the severity and duration of the disease. Diagnosis is made by colonoscopy with mucosal biopsies.

Extracolonic manifestations often are present in patients with IBD. Fatty infiltration of the liver is present in 40% to 50% of patients. Many patients with sclerosing cholangitis also have ulcerative colitis. In this situation, removing the colon does nothing to reverse the effects on the liver. Liver transplantation becomes the only treatment option. (1) The incidence of arthritis in patients with IBD is 20 times greater than in the general population. Sacroiliitis and ankylosing spondylitis also are associated with ulcerative colitis. Up to 10% of patients with IBD will develop ocular lesions, including uveitis, episcleritis, and conjunctivitis. (4) Treating the colonic disease, however, does not seem to affect extracolonic manifestations.

Patients with IBD often are malnourished because of abdominal pain and diarrhea. This malnourishment causes significant protein loss. Continual inflammation produces a catabolic physiological state. The inflamed bowel is unable to absorb water or perform active transport or passive diffusion of ions. The normal physiology of the colon, as described above, is completely disrupted. Although quite ill, patients may force themselves to function normally despite the pain and discomfort they may be experiencing. Anemia is not always present, but many patients function with iron-poor blood for prolonged periods of time. When the diseased organ is removed, patients realize how depleted they were of iron, electrolytes, calories, and energy.

MEDICAL MANAGEMENT

Oral or parenteral corticosteroids are used to combat acute exacerbation of ulcerative colitis. Although this treatment can be effective, the serious side effects of long-term steroid use are numerous. Locally administered therapy for proctitis and proctosigmoiditis consists of corticosteroid enemas and 5-acetylsalicylic acid (ie, 5-ASA) delivered either by enema or suppository. These therapies also can be effective for colitis that is confined to the distal colon.

Toxic megacolon is a life-threatening complication of ulcerative colitis, Crohn's colitis, salmonellosis, ischemic colitis, and pseudomembranous colitis. Patients with toxic megacolon are extremely ill. Although medical management may be attempted, it should be regarded as preparation for urgent surgery unless the condition improves promptly.

INDICATIONS FOR SURGICAL MANAGEMENT

Surgery is necessary for patients with ulcerative colitis whose medical therapy has failed. In some situations, maximum medical therapy carries its own complications, as in the case of long-term, high-dose steroid treatment. Some patients with ulcerative colitis are concerned about the associated risk of cancer. Risk of malignancy increases with the extent and duration of the disease, even if it is quiescent. In fact, individuals with ulcerative colitis are 30 times more likely to develop colorectal cancer than members of the unaffected population. (5) The cumulative cancer risk for any patient with ulcerative colitis is 2% at 10 years, 8% at 20 years, and 18% at 30 years. (5)

Patients who experience life-threatening hemorrhage, toxic megacolon, or fulminant colitis need emergent surgical management, which usually consists of a total abdominal colectomy with end ileostomy. Definitive surgery can be performed at a later date to remove the affected rectum and potentially create an ileal pouch.

SURGICAL OPTIONS

Total proctocolectomy and ileostomy is the curative surgical treatment for ulcerative colitis. This involves removing the entire colon, rectum, and anus. The ileum is brought to the skin to create an end ileostomy (ie, Brooke ileostomy) or a continent ileostomy (ie, Koch pouch). In these situations, the anal sphincter is not spared. The difference between the two ileostomies includes not only their construction but also their function.

BROOKE ILEOSTOMY. A Brooke ileostomy is considered a permanent ileostomy when it is performed with a total proctocolectomy. The ileum is drawn through a circular incision on the abdominal wall. If the procedure is planned in advance, an enterostomal therapy nurse will mark a location on the patient's abdomen that matches the patient's contours, waist and belt line, and body habitus. Patients who are prepared ahead of time for the placement of a stoma can adjust more easily postoperatively to its care and management. The output (ie, effluent) of this stoma is high in water and electrolyte content. It is not considered a continent stoma because the effluent flows freely without the patient controlling it.

KOCH POUCH. Koch pouches are known as continent stomas because patients must insert a tube to evacuate the contents. Patients do not have to wear external appliances as do patients with Brooke ileostomies. Approximately 10 cm of ileum is used to create a nipple-valve. An additional 30 cm of ileum is needed to create the pouch within which the valve will be seated. The pouch acts as a reservoir for liquid stool that becomes more pasty over time. The pouch needs to be trained initially by being drained continuously during a two-week period. Gradually, patients move from emptying the reservoir every three hours to three or four times per day. This technique has resulted in a significant rate of obstruction and incontinence and often requires revision. Most often, the nipple valve must be reconstructed. (4)

RESTORATIVE PROCTOCOLECTOMY. An alternative procedure for ulcerative colitis is a restorative proctocolectomy with ileal pouch-anal anastomosis. Proctocolectomy eliminates diseased colon, but in this case, the anal sphincter is spared, and therefore, anal continence can be preserved. (6) A neorectum (ie, ileal pouch) is created with distal ileum to form a reservoir to hold GI contents. This neorectum never fully matches the rectum in function or capacity, but it is a viable alternative. Depending on the available length of small bowel, a "J" pouch (Figure 2), "S" pouch (Figure 3), or "W" pouch (Figure 4) is created. (7)

[FIGURES 2-4 OMITTED]

When the pouch is created, it is connected to the distal anal stump. This can be achieved using an open purse-string technique with a circular stapler. Alternatively, the surgeon can employ a double-staple technique, joining the pouch and anal stump through a transverse staple line.

The anastomotic line from the pouch to the anus may require healing time before the fecal stream is allowed to pass through it. For this reason, a temporary ileostomy may be created. This can be a divided loop ileostomy wherein a small loop of bowel is drawn through the abdominal wall. One end is closed and tacked up to the inside of the abdominal wall for easy access when the loop eventually is taken down. The other end is opened and everted to create an ileostomy to which an appliance can be fitted. An ileostomy with two openings includes an open stoma for effluent and another stoma for a mucous fistula. This second stoma does not pass stool, only mucus, and requires an appliance.

PREOPERATIVE PREPARATION

Patients who present as surgical candidates for ulcerative colitis treatment have exhausted all medical treatment options. Those who do not present emergently are given several surgical choices for treatment of their condition. It is essential, as part of the initial surgical consultation visit, to have records of recent colonoscopy and pathology results of any biopsies taken. A rectal examination should be performed to assess sphincter tone. Poor sphincter tone precludes the creation of an ileal pouch. Curing ulcerative colitis but leaving the patient incontinent of feces does the patient a great disservice.

PATIENT EDUCATION. Depending on the patient's condition, the surgeon may suggest a restorative proctocolectomy procedure as a viable alternative if the patient does not want to live with a permanent ileostomy. The nurse provides the patient with a teaching booklet that describes the procedure. The nurse and surgeon explain what to expect when the procedure is finished. The patient must understand that the pouch, although created as a rectal reservoir, in fact takes time to adapt and perform as a reservoir. The nurse explains that the patient can expect to have up to 10 stools per day until the body adjusts to the new configuration. Typically, the patient will experience a decrease hi the number and frequency of stools when bowel continuity is restored. This may take three months or more.

EXAMINATION AND LABORATORY REQUIREMENTS. If the patient agrees to surgery, his or her primary care physician or nurse practitioner performs a complete history and physical and orders a complete hemogram with differential and comprehensive metabolic panel to be drawn preoperatively. Patients who have experienced weight loss and severe diarrhea also have a nutritional profile drawn, which includes albumin, prealbumin, and transferrin levels. If the patient is anemic, transfusion of one or more units of packed red blood cells may be prescribed. If the patient requires an anticoagulant, he or she comes into the hospital a few days early to receive a heparin bridge until the time of surgery. This is to bridge the change from oral anticoagulation to subcutaneous heparin. The heparin is continued after surgery until the patient can resume taking oral anticoagulation medication, if necessary.

A week before surgery, the patient meets with the enterostomal therapy nurse to be marked for a temporary ileostomy. At this time, the nurse answers questions about postoperative stoma care and makes dietary suggestions. This is an important time for the patient to discuss his or her concerns regarding body image, sexuality, physical activities and restrictions, and overall adjustments to life with a temporary stoma. This is an essential aspect of preoperative teaching that should not be omitted.

A few days before surgery, a nurse from the preadmission nursing department contacts the patient to confirm the date and time of surgery, review medical history and preoperative orders, discuss advanced directives and pain control, and answer any questions the patient may have regarding his or her admission. Typically, the patient is admitted the morning of surgery.

BOWEL PREPARATION, The surgeon routinely prescribes a full mechanical bowel cleansing and preoperative antibiotics. Unless contraindicated, the surgeon prescribes one gallon of polyethylene glycol to be consumed by the cupful every 15 minutes until gone, beginning the afternoon before surgery. In addition, he or she prescribes two different oral antibiotics to be taken at three distinct intervals before bedtime. The purpose of these antibiotics is to minimize the risk of infectious complications to bowel surgery (eg, wound infection, intra-abdominal or pelvic abscess) caused by endogenous colonic bacteria. (8) After the patient has completed the bowel cleansing and consumed the oral antibiotics, he or she is instructed to remain NPO after midnight.

The colon rectal surgery nurse coordinator organizes preoperative preparation for patients undergoing surgery and participates intraoperatively as needed. Postoperatively, he or she sees the patient in the hospital and clinic and troubleshoots at-home difficulties. The nurse coordinator develops a care plan to ensure continuity of care during the intraoperative period (Table 1). (9)

PREOPERATIVE ANXIETY. The nurse coordinator uses general surgery and specific procedure teaching booklets. Patients often call with questions that already have been answered, however, because their preoperative anxiety is so high that their ability to retain information is impaired. Hearing the same information from a variety of sources can help alleviate some of the patient's anxiety.

Patients who have had previous surgical experiences often are very anxious about pain control. Although epidural anesthesia has been used for postoperative pain control, more commonly a patient-controlled analgesia pump is employed. Effective pain management means that the patient is able to ambulate early and often. This promotes bowel function and hastens the time until the patient can begin to orally consume foods and fluids. When the patient can consume oral fluids and soft foods, oral pain medications are offered. As activity increases, however, pain also may increase.

Although many patients have an intellectual understanding of the need for an ileostomy, it takes some time to adjust to having one. Patients often are uncertain about what to eat and how to slow down their output in the three to four weeks after surgery. Patients receive a lot of support from enterostomal therapy nurses and ostomy support groups; however, the adjustment still may be difficult for some patients. As the time approaches for restoring bowel continuity (ie, the ileostomy take-down procedure), patients usually are eager to undergo this additional procedure.

PERIOPERATIVE CARE

Patients who have a restorative proctocolectomy differ from one another in terms of their state of health, understanding of their illness and treatment, and the implications for their lifestyle. Preoperative assessment, therefore, is tailored to each patient's individual situation.

The preoperative nurse confirms the patient's identity by wristband and verbal acknowledgement from the patient. He or she also checks the admission face sheet to verify the patient's identity and medical record number. The nurse reviews the surgical consent for completeness, including signatures from both the patient and the surgeon. The nurse then asks the patient to explain his or her understanding of the procedure. This understanding is especially important for patients who will wake up with a stoma. For example, in one situation, a patient looked at the nurse in surprise and anger when the nurse mentioned a stoma, despite the fact that the patient had been informed and premarked for the ileostomy. The patient clearly had not grasped the pending reality, and surgery was nearly cancelled.

The nurse performs a head-to-toe assessment after reviewing information from the preoperative history and physical examination. The nurse assesses the patient's skin integrity and notes the need for sensory aids (eg, glasses, contact lenses, hearing aids). The patient may be allowed to keep his or her glasses and hearing aids until induction begins. The circulating nurse will make special adjustments in positioning if he or she identifies that the patient has physical limitations, such as a decrease in range of motion or a joint implant.

The nurse places a large bore IV line while the patient is in tire preoperative holding area. He or she then places sequential compression stockings over thigh-high elastic stockings on the patient's legs. If warranted, the nurse administers subcutaneous heparin at this time.

The circulating nurse and anesthesia care provider arrive in the preoperative holding area, and each completes an assessment of the patient. The patient then is transferred to the OR. If the anesthesia care provider placed an epidural catheter preoperatively, he or she ensures proper positioning of the catheter before general anesthesia induction.

POSITIONING AND PREPPING. The circulating nurse and surgeon place the patient in the lithotomy position, which allows access to both the abdomen and perineum. Before scrubbing, gowning, and gloving, the surgeon usually performs a rectal examination and proctoscopy to suction out any remaining stool in the distal rectum. The circulating nurse performs two preps--one of the patient's abdomen and the other of the perineum--with an antimicrobial solution. The surgeon and scrub person drape the patient allowing for future access to the perineum when the colon is ready to be removed. When the perineum is accessed, the surgeon uses a second Mayo stand setup and changes gown and gloves before returning to the abdominal portion of the procedure.

THE PROCEDURE. Surgical team members (eg, surgeon, circulating nurse, anesthesia care provider, scrub person) cooperatively confirm the patient's identity and planned procedure as stated on the written consent form before making the initial incision. A restorative proctocolectomy typically takes between three and five hours to perform. It is a technically challenging procedure that requires detailed knowledge about blood and nerve supply to the small and large bowel and mesentery. Using the small bowel to create a neorectum is difficult. Fitting it into the pelvic floor and having it function requires advanced technical skill and anatomical knowledge of the surrounding structures.

Both the circulating nurse and scrub person have to be flexible to adjust to the demands of the surgical procedure. The patient's diseased and inflamed colon can cause adhesion formation. The surgeon may require extra time to perform adhesiolysis if needed. Surgical team members may have to shift between the abdominal incision and the perineum and back again, requiring multiple gown and glove changes and diligence in maintaining the sterile field. Switching from deep pelvic instruments to short ones and back again and adjusting tie length and suture requires that the nurse be alert to the changing needs of the surgeon and the demands of the patient's specific anatomy.

The surgeon begins the procedure with an exploratory laparotomy. If there are no unexpected findings, the surgeon proceeds with a colectomy in the usual fashion with the exception of mobilizing the rectum. This is performed differently so that pelvic nerve integrity is preserved to maintain sexual function in males. The surgeon dissects the distal sigmoid colon from the mesentery and ligates the inferior mesenteric vessels without disturbing the presacral sympathetic plexus. He or she uses electro-surgery carefully to avoid damaging the parasympathetic pelvic nerves that enter deep in the pelvis in an anterolateral direction. The surgeon mobilizes the entire rectum to the levator ani muscle.

The surgeon may perform a transanal mucosal sleeve resection, taking care to avoid damaging the internal and external sphincter muscles. He or she separates the lining of the distal anal canal from the underlying internal sphincter muscle. When the dissection meets with the mobilized rectum from above, the surgeon removes the specimen (Figure 5).

[FIGURE 5 OMITTED]

To make the pouch configuration, the surgeon transects the terminal ileum flush with the cecum and then accurately measures the length needed to create the pouch for attachment to the anus. This is to ensure that the apex of the pouch reaches the anus without tension and that blood supply is preserved. At this time, the surgeon configures the pouch, whether J-, S-, or W-shaped. The surgeon pulls the ileal pouch through the denuded anorectum and hand sutures the anastomosis to the dentate line of the anal canal.

An alternative and frequently used technique involves double-stapling. The surgeon closes the distal anal canal with a transverse stapler and uses an end-to-end circular stapler to staple the ileal pouch to the anal stump. The surgeon checks to make sure that the donut-shaped tissue that comes out of the stapler is complete and of equal size and thickness. He or she may place a drain in the presacral space and bring it out through a stab wound in the left lower quadrant. To check for leaks, the surgeon at the rectal site inserts a proctoscope into the anus. The surgeon gently pumps in air with the bulb attachment. The surgeon at the abdominal wound watches for bubbles as air enters the newly formed pouch. If there are none, the anastomosis is free of leaks. If bubbles occur, the surgeon needs to manually oversew the anastomosis.

When the surgeon is satisfied with the anastomosis, he or she may create a divided loop ileostomy using a loop of ileum as close to the pouch as possible. He or she brings the loop out through the spot marked preoperatively by the enterostomal nurse. Careful attention is paid to ensure that the loop is not twisted when anchored. The surgeon then opens it transversely, closer to the distal limb. The proximal limb is everted and secured so an appliance can be fitted.

The surgeon irrigates the patient's abdomen and close it in the usual fashion. The scrub person attaches the drain to its reservoir and helps the surgeon size and fit an appliance over the newly constructed ileostomy.

Surgical team members transfer the patient to the postoperative stretcher, ensuring proper positioning and checking all boney prominences for breakdown. The circulating nurse covers the patient with warm blankets and helps the anesthesia care provider transfer the patient to the postanesthesia care unit.

The patient remains in the hospital between four and seven days and is NPO until gas is passed through the stoma. Slowly, the patient's diet progresses from ice chips to small sips of liquids to a soft diet and then to a low insoluble-fiber diet. The surgeon assesses bowel function at each stage of diet progression.

POSTOPERATIVE CARE

The greatest postoperative challenge is to keep ileostomy output less than 1,500 mL per day. Initially, the output is quite high. Each patient is taught to measure output and is instructed to call the clinic if output exceeds a set limit. The effluent is rich in electrolytes; therefore, when output is high, electrolyte loss also is high. The patient may need to be readmitted for rehydration and electrolyte replacement. Barring any complications, the patient typically returns to the clinic two weeks after discharge. The surgeon and nurse assess wound healing, the health of the stoma, and the quantity and quality of its output. An enterostomal therapy nurse meets with the patient regularly to treat any peristomal skin problems that the patient may be experiencing. Stoma size initially may be larger as a result of postoperative swelling. For this reason, an enterostomal therapy nurse meets with the patient regularly to refit the appliance as the stoma assumes its normal size. This relationship lasts for several weeks, even after the patient undergoes the ileostomy take-down procedure.

Postoperative recovery requires a team approach, including active patient participation. Fatigue is common, particularly if the patient begins to feel well enough to return to his or her normal activities. Full recovery requires approximately six weeks or longer.

Typically, patients return to the hospital after approximately three months to have the temporary ileostomy taken down to restore bowel continuity. The first step to ensure that there is an intact suture line at the pouch anastomosis is to perform a gastrografin enema. A flexible, small rubber catheter without a balloon is gently inserted into the pouch via the anus. The surgeon injects gastrografin dye while an x-ray is taken. The dye should remain in the pouch without any extravasation. The surgeon also examines the patient to check the anastomosis and ileal pouch. If these tests are normal, it is safe to proceed with restoring bowel continuity. Recovery time is shorter after the ileostomy take-down procedure and usually requires only four days in the hospital.

POSTOPERATIVE COMPLICATIONS

Although the restorative proctocolectomy procedure provides patients with an alternative to permanent ileostomy, it carries with it risks and potential complications. Patients undergoing restorative proctocolectomy may experience anal stricture, pelvic abscess, pouchitis, pouch fistula, pouch leakage, pouch failure, sexual dysfunction, or small bowel obstruction.

ANAL STRICTURE. Anal canal stricture at the site of the anastomosis is common. Mild strictures may be dilated with a 1-cm proctoscope. More severe strictures may require dilation under anesthesia with Hegar dilators.

PELVIC ABSCESS. Pelvic abscesses occur in 4% to 6% of patients. (1,2) Symptoms include fever, pelvic or low-back pain, and elevated white blood cell count. A computerized tomography (CT) scan is used for diagnosis and may allow for CT-guided drainage of the abscess with the drain left in place. In more severe cases, an exploratory laparotomy is necessary to drain the abscess and, potentially, remove the pouch. The surgeon would reestablish the ileostomy in this situation.

POUCHITIS. The ileal pouch itself becomes inflamed, giving the patient a sense of urgency and frequency that sometimes results in fecal soiling at night. Treatment consists of antibiotics (eg, metronidazole) for 10 days to two weeks. In some situations, longer-term antibiotics may be prescribed.

POUCH FISTULA. A fistula can result if the area of the anastomosis does not heal properly or an abscess breaks through the tissue. This is more common in patients who have not undergone a temporary diverting ileostomy. In other situations, Crohn's disease must be ruled out. Treatment options include intraoperative application of a fibrin material, which delays closure of the ileostomy, in an attempt to close the passageway or reestablishing the ileostomy if it already has been taken down.

POUCH LEAKAGE. Asymptomatic leaks usually are detected when the patient is ready for his or her ileostomy takedown procedure. The gastrografin dye will show a leak, often in the posterior aspect of the pouch. The take-down procedure, therefore, is delayed. Sometimes the patient will be brought to the OR to have the leak curetted and fibrin glue injected into the site of the leak. A few months of healing are required before another gastrografin enema is attempted. If the pouch fails to heal, Crohn's disease may be the cause. Depending upon the severity of the Crohn's disease and the location of patchy ulcerations indicative of the disease, the pouch may need to be removed. Medical therapy for Crohn's disease also may be initiated.

POUCH FAILURE. Pouch failure occurs when the reservoir functions poorly and causes excess frequency or incontinence. Patients with persistent pouchitis, severe pelvic infections not responsive to medical therapy, or Crohn's disease are at risk for pouch failure. Excision of the pouch may become necessary, which requires creation of a permanent ileostomy.

SEXUAL DYSFUNCTION. Sexual dysfunction in the form of impotence or retrograde ejaculation occurs in 1% to 3% of male patients despite care taken in the intraoperative dissection of the presacral pelvic nerves. Dyspareunia occurs in 7% of female patients with 2% reporting involuntary leakage of stool during intercourse. (4)

SMALL BOWEL OBSTRUCTION. Small bowel obstruction occurs in 15% to 40% of patients after restorative proctocolectomy. Between 5% and 20% of the time, surgery is required to relieve the obstruction. (4) After the ileostomy is taken down, adhesion bands cause most obstructions.

CASE STUDY

Mr K was referred to the colon and rectal surgery department at the University of Minnesota Physicians, Minneapolis, because of intractable ulcerative colitis with bloody diarrhea. At 40 years of age, his history included chronic use of high-dose steroids to control symptoms. This therapy eventually resulted in avascular necrosis of his hip. He underwent a total hip arthroplasty but suffered a deep vein thrombosis postoperatively. After initial heparin therapy, Mr K was converted to daily warfarin. His internal medicine physician monitored this therapy.

Before being referred to the colon and rectal surgery department, Mr K received four units of packed red cells as an outpatient. His hemoglobin hovered around the 10-gm to 11-gin range. The colon rectal surgery coordinator spoke with Mr K several times to convince him to be evaluated for surgical treatment of ulcerative colitis. Clearly, the disease was life altering for him, and it was affecting his work. He had little stamina but insisted that he could not take three months off from work to have surgery and recover. The initial goal was to encourage him to come to the colon rectal clinic to be assessed.

After a thorough examination, the surgeon discussed the options for surgical treatment. He proposed a restorative proctocolectomy with ileal pouch-anal anastomosis and temporary loop ileostomy. Mr K agreed to the surgery, but it was clear that he was very fearful. Mr K was preadmitted to the hospital to

* establish a heparin bridge because of his warfarin maintenance,

* receive blood if necessary to build up his hemoglobin, and

* have bilateral lower extremity ultrasound performed to assess for the presence of preoperative clots.

Mr K was at risk for injury and for acute and chronic pain. Additionally, he was at risk for unrealistic expectations regarding recovery and his ability to withstand his illness. Nurses felt his bravado was an attempt to hide his fear.

Surgery was performed without incident, and Mr K had good pain control postoperatively. His stoma output was low enough to manage at home, so he was discharged after one week. Two days after being discharged, Mr K called the clinic to report that he was vomiting; however, he failed to mention that he was emptying his stoma appliance hourly. He clearly had exceeded the 1,500 mL per 24 hour limit. The nurse coordinator insisted that he come to the clinic for an evaluation. Although Mr K was hesitant, he finally agreed to come to the clinic. After an evaluation, Mr K was hospitalized immediately for dehydration.

Rehydration was accomplished easily, but slowing down stomal output was more difficult. Stool thickeners, such as psyllium mixed with half the required amount of water along with loperamide were used cautiously as caregivers endeavored to avoid causing an obstruction. Mr K remained in the hospital for another week, as his output gradually decreased. As was his habit, Mr K verbally minimized his preadmission symptoms and explained that he was in control of the situation.

A week later, the nurse coordinator discovered that Mr K had been admitted emergently for profuse bleeding from his incision site and his neorectum. He had been taking his warfarin as planned, but he had independently added a nonsteroidal, anti-inflammatory medication for pain control rather than his prescribed pain medications, which dramatically altered his platelet function. Upon admission, Mr K's platelet count was 1,000 per [mm.sup.3]. A normal platelet count is 100,000 per [mm.sup.3] to 500,000 per [mm.sup.3].

The most obvious site for bleeding was his fresh anastomosis. The surgeon examined the anastomosis and oversewed it in the OR. Mr K's anastomosis continued to ooze and his hematocrit continued to drift downward, so he remained in the intensive care unit where he was given fresh frozen plasma and platelets. With time, Mr K began to clot and recovered well enough to be discharged home. He struggled with depression about lack of control over his own body. Before surgery, Mr K was nonchalant about the seriousness of his condition and the procedure. Readmission forced him to face his limitations.

Staff members at the colon rectal surgery clinic monitored Mr K closely for several weeks. He begged to return to work before his recovery period was complete. He also developed a superficial wound infection that required minor debridement in the clinic. His initial three-month recovery time was extended as was his ultimate ileostomy take-down procedure. Fortunately, by the time this second procedure was scheduled, he had recovered enough to undergo the procedure without complications.

Despite the readmissions and the fearful time that Mr K experienced, he was grateful to have had the surgery. He said that he had no idea why he had postponed surgery for as long as he had. His reserves were very nearly depleted by the time of his first appointment at the clinic. Fortunately, he is doing well and is back to work full time.

DEFINITIVE TREATMENT

Ulcerative colitis is a serious illness affecting the colon. Normal physiological processes cannot occur in a colitic colon so patients suffer from fluid loss, bloody diarrhea, and cramping abdominal pain. Although the disease is mild in some patients, there is a cancer risk associated with ulcerative colitis related to duration and extent of the disease.

Medical management usually consists of corticosteroid treatment along with localized treatment in the rectum. Surgical treatment, however, is the only definitive way to remove the disease in its entirety. This can be achieved by a total proctocolectomy and ileostomy. If appropriate, patients who do not wish to have a permanent stoma can be given the option of undergoing a restorative proctocolectomy with ileal pouch-anal anastomosis.

Editor's note: The author acknowledges David A. Rothenberger, MD, professor of surgery, and chief, division of colon and rectal surgery at the University of Minnesota, Minneapolis, and Mary Goff, executive assistant to the associate director for clinical research and programs at the University of Minnesota Cancer Center, Minneapolis, for their time and assistance with this article.

NOTES

(1.) K M Bullard, D A Rothenberger, "Colon, rectum, and anus," in Principles of Surgery, eighth ed, C Brunicardi et al, eds (New York: McGraw-Hill) in press.

(2.) W H Shouten, P H Gordon, "Physiology," in Principles and Practice of Surgery for the Colon, Rectum, and Anus, second ed, P H Gordon, S Nivatvongs, eds (St Louis: Quality Medical Publishing, Inc, 1999) 41-86.

(3.) D K Bonnen, J H Cho, "The genetics of inflammatory bowel disease," Gastroenterology 124 (February 2003) 521-536.

(4.) S Nivatvongs, Ulcerative colitis," in Principles and Practice of Surgery for the Colon, Rectum, and Anus, second ed, P H Gordon, S Nivatvongs, eds (St Louis: Quality Medical Publishing, Inc, 1999) 831-906.

(5.) J A Eaden, K R Abrams, J F Mayberry, "The risk of colorectal cancer in ulcerative colitis: A meta-analysis," Gut 48 (April 2001) 526-535.

(6.) U A Heuschen et al, "One or two-stage procedure for restorative proctocolectomy, rational for a surgical strategy in ulcerative colitis," Annals of Surgery 234 (December 2001) 788-794.

(7.) D A Rothenberger, "Atlas of colon and anorectal surgery," in Digestive Tract Surgery: A Text and Atlas, ed R H Bell, L R Rikkers, M W Mulholland (Philadelphia: Lippincott-Raven Publishers, 1996) 1524-1527.

(8.) O Zmora, A J Pikarsky, S D Wexner, "Bowel preparation for colorectal surgery," Diseases of the Colon and Rectum 44 (October 2001) 1537-1549.

(9.) S Beyea, ed, Perioperative Nursing Data Set, second ed (Denver: AORN, Inc, 2003).

Examination

Ulcerative colitis--Diagnosis and surgical treatment

1. In patients with ulcerative colitis, normal bowel physiology is not possible because

1. all colonic functions are lost.

2. mucosal hypertrophy occurs.

3. water absorption occurs actively as it follows the transported potassium.

4. ammonia absorption increases.

a. 1

b. 2 and 4

c. 1, 2, and 3

d. 1, 2, 3, and 4

2. Inflammatory bowel disease may be caused by

1. a defect in the immune system.

2. diet.

3. drinking alcohol.

4. genetics.

5. infection.

6. smoking.

a. 1, 3, and 5

b. 2, 4, and 6

c. 1, 3, 4, and 6

d. 1, 2, 3, 4, 5, and 6

3. The key component to diagnosing ulcerative colitis is homogenous involvement of the

a. proximal ileum.

b. rectum and colon.

c. small intestine.

4. Toxic megacolon can only be treated with

a. 5-acetylsalicylicc acid.

b. corticosteroid enemas.

c. parenteral corticosteroids.

d. surgery.

5. Patients with ulcerative colitis often experience extracolonic manifestations, such as

1. arthritis.

2. chronic glomerulonephritis.

3. fatty infiltration of the liver.

4. interstitial hepatitis.

5. ocular lesions.

6. sclerosing cholangitis.

a. 1, 2, and 5

b. 2, 3, and 4

c. 1, 3, 5, and 6

d. 1, 2, 3, 4, 5, and 6

6. Risk of malignancy does not increase if ulcerative colitis is quiescent.

a. true

b. false

7. A restorative proctocolectomy

1. eliminates the diseased colon.

2. preserves anal continence.

3. removes a large portion of the diseased ileum.

4. spares the anal sphincter.

a. 1 and 2

b. 3 and 4

c. 1, 2, and 4

d. 1, 2, 3, and 4

8. During a restorative proctocolectomy procedure, the distal ileum is used to make a reservoir to contain gastrointestinal contents. This is called a/an

a. Brooke ileostomy.

b. continent ileostomy.

c. Koch pouch.

d. ileal pouch.

g. For nonemergent restorative proctocolectomy, preoperative preparation includes

1. a blood transfusion if the patient is anemic.

2. bowel preparation.

3. blood work, including a hemogram and metabolic panel.

4. being marked for a temporary ileostomy.

5. a rectal examination to assess sphincter tone.

6. patient education regarding pouch adaptation.

a. 1, 3, and 5

b. 2, 4, and 6

c. 1, 3, 4, and 6

d. 1, 2, 3, 4, 5, and 6

10. If a patient is experiencing urgency and frequency that sometimes results in fecal soiling at night, he or she may have the postoperative complication of

a. anal stricture.

b. pouchitis.

c. pouch fistula.

d. small bowel obstruction.

Answer Sheet

Ulcerative colitis--Diagnosis and surgical treatment

Please fill out the application and answer form on this page and the evaluation form on the back of this page. Tear the page out of the Journal or make photocopies and mail to:

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Mark only one answer per question.

[ILLUSTRATION OMITTED]

Learner Evaluation

Ulcerative colitis--Diagnosis and surgical treatment

Objectives

To what extent were the following objectives of this Home Study Program achieved?

1. Describe inflammatory bowel disease.

2. Discuss treatment options for patients with ulcerative colitis.

3. Explain the perioperative care provided for patients undergoing restorative proctocolectomy.

4. Identify potential postoperative complications of restorative proctocolectomy.

Content

5. Did this article increase your knowledge of the subject matter?

6. Was the content clear and organized?

7. Did this article facilitate learning?

8. Were your individual objectives met?

9. How well did the objectives relate to the overall purpose/goal?

Test Questions/Answers

10. Were they reflective of the content?

11. Were they easy to understand?

12. Did they a d dress important points?

Learner Input

13. Will you be able to use the information from this Home Study in your work setting?

a. yes b. no

14. I learned of this Home Study via

a. the Journal I receive as an AORN member.

b. a Journal I obtained elsewhere.

c. the AORN web site.

d. SSM Online.

15. What factor most affects whether you take an AORN Journal Home Study?

a. need for contact hours

b. price

c. subject matter relevant to current position

d. number of contact hours offered

What other topics would you like to see addressed in a future Home Study Program? Would you be interested or do you know someone who would be interested in writing an article on this topic?

Topic(s): --

Author names and addresses: --

Session Number

[ILLUSTRATION OMITTED]

The article "Ulcerative colitis--Diagnosis and surgical treatment" is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, BC, education program professional, Center for Perioperative Education.

Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of completion. The deadline for submitting this study is August 31, 2007.

Complete the examination answer sheet and learner evaluation found on pages 265-266 and mail with appropriate fee to

AORN Customer Service

c/o Home Study Program

2170 S Parker Rd, Suite 300

Denver, CO 80231-5711

or fax the information with a credit card number to (303) 750-3212.

You also may access this Home Study via AORN Online at http://www.aorn.org/journal/homestudy/default.htm.

BEHAVIORAL OBJECTIVES

After reading and studying the article on diagnosing and surgically treating ulcerative colitis, nurses will be able to

1. describe inflammatory bowel disease,

2. discuss treatment options for patients with ulcerative colitis,

3. explain the perioperative care provided for patients undergoing restorative proctocolectomy, and

4. identify potential postoperative complications of restorative proctocolectomy.

Patricia Stein, RN, MAOL, CNOR, is the nurse coordinator for the colon and rectal surgery department at the University of Minnesota Physicians, Minneapolis.

COPYRIGHT 2004 Association of Operating Room Nurses, Inc.
COPYRIGHT 2004 Gale Group