Inflammatory bowel disease
Inflammatory bowel diseases (IBDs) affect four in 1000 people in industrialized countries. The two main types of IBD are Crohn’s disease and ulcerative colitis. Crohn’s disease is a chronic inflammatory process which may affect any part of the gastrointestinal tract from the mouth to the anus. The inflammation is transmural and may be complicated by fistulas, abscess formation, and intestinal strictures. In contrast, ulcerative colitis only affects the colon; inflammation is superficial, starts at the anus and may extend to the caecum (pancolitis), or affect only the rectum (proctitis).
Ulcerative colitis classically presents with bloody diarrhoea, colicky abdominal pain, and urgency. The course is one of relapses and remissions with up to 50 per cent of patients relapsing a year. After the first year 90 per cent of patients are able to work fully. There is a slight increase in mortality in the 2 years following diagnosis but this then reverts to that of the normal population. There is a cumulative risk of colorectal cancer of 7.6 per cent at 30 years and 10.8 per cent at 40 years from diagnosis.
Aminosalicylates are used in mild presentation and for maintenance, where they reduce relapse rates by up to 80 per cent and reduce the risk of colorectal cancer. Rectal preparations are the first- line treatment for proctitis. Reducing courses of oral prednisolone are used in more severe flares. In steroid-dependent patients, azathioprine or mercaptopurine is used as a steroid-sparing agent. These patients need monitoring because of potential bone marrow suppression. Ciclosporin or infliximab can be used for rescue therapy on an in-patient basis and reduce the need for surgery. Despite medical treatment 20-30 per cent of patients with pancolitis will eventually undergo colectomy.
Ileostomy and ileo-anal pouch
An ileostomy may be fashioned temporarily or permanently. Stomal complications from a permanent ileostomy for ulcerative colitis occur in 75 per cent of patients over 20 years. Stomas have a greater impact on the quality of life of females than males. Ileo-anal pouch procedures are increasingly being performed in patients with ulcerative colitis, with improved social acceptability, work capacity, and quality of life. Frequency of defecation, up to six times per day, may be a problem. There is a significant incidence of sexual dysfunction in males following the procedure. Seventy per cent of patients with a pouch will suffer a complication necessitating hospital admission, up to 30 per cent develop pouchitis, and excision of the pouch is necessary in about 10 per cent.