Ulcerative Colitis

Description

Ulcerative colitis is an inflammatory bowel disease that is characterized by inflammation leading to ulcers in the large intestine. It usually involves the rectum may extend more proximally to involve the colon.
Patients present in the perioperative period for colectomies (curative), ileostomy-related procedures, or management of non-related problems.

Epidemiology

Incidence

US: 2–14 cases per 100,000 (1)
Bimodal distribution with diagnosis peaking between ages 15 25 then in the 50s

Prevalence

More common in females (2)

Morbidity

The ultimate cure is colectomy
Patients suffer from flare-ups that can cause significant discomfort weight loss.

Mortality

Low, but there is an increased rate of colorectal cancers.

Etiology/Risk Factors

The exact cause of ulcerative colitis (UC) is unknown, but immune system abnormalities environmental factors have all been postulated as causes of UC (3).
There is a genetic predisposition as evidenced by familial twin studies.

Physiology/Pathophysiology

UC is an inflammatory bowel disease that leads to cell necrosis the development of ulcers. These ulcers bleed produce pus.
Cause: Evidence suggests that normal intestinal flora can trigger an aggressive inappropriate immune reaction in patients with a multifactorial genetic predisposition. No specific environmental, dietary, or infectious causes have been identified.
Inflammation is often confined to the mucosa of the colon rectum; whereas in Crohn's disease, it is transmural. Additionally, with UC there is continuous, adjacent involvement; whereas in Crohn's disease, it is patchy cobble-stoned.
- Cytokine release includes interleukin-1 (IL-1) which causes diarrhea acts as a pyrogen. Other cytokines released include IL-6, IL-8, tumor necrosis factor- (TNF-).
- Neutrophils mononuclear cells are believed to cause cryptitis crypt abscesses.
- Cytokines lead to differentiation of lymphocytes to T cells (mainly Helper T cells Type 2), leading to immune system activation, inflammatory response, subsequent damage of the intestinal mucosa.
Diarrhea pain can cause electrolyte abnormalities malnutrition.
Anemia occurs due to blood loss (acute or chronic) due to malabsorption of iron, vitamin B12, folate.
Diagnosis can be made with a biopsy of affected tissue via endoscopy.
Imaging with plain films CT scan can aid in diagnosis, especially diagnosing complications such as toxic megacolon

Anesthetic GOALS/GUIDING Principles

Assess the severity of the disease concomitant organ dysfunction.
Anesthetic plan should focus on fluid electrolyte management, assessment of anemia, use of steroids.

Diagnosis ⬆ ⬇

Symptoms

Exacerbations consist of diarrhea with blood mucus, abdominal cramping, bloating, acute pain, weakness, rectal bleeding, fevers, weight loss, pain in the lower left abdomen.
Toxic megacolon can occur in severe cases when impaired colonic motility is present. This can lead to perforation.

History

Severity of chronic condition
Recent acute flares
Co-morbidities complications of therapy such as diabetes hypertension from chronic steroid use.

Signs/Physical Exam

Signs of dehydration: Decreased skin turgor, capillary refill, urinary output, blood pressure as well as tachycardia
Signs of electrolyte abnormalities: Muscle weakness
Malnutrition vitamin deficiencies
Painful lower extremity swelling may indicate a deep venous thrombosis (increased risk); shortness of breath may indicate a pulmonary embolus

Treatment History

Surgical resection of the colon is a treatment option for severe disease for toxic megacolon unresponsive to medical treatment.
Total parenteral nutrition (TPN)

Medications

Antiinflammatories: Maintenance therapy includes 5-aminosalicylic acid, steroids (prednisone), immunomodulators such as azathioprine, cyclosporin, infliximab for refractory disease (4).
Diagnosis is via biopsy of affected tissue on sigmoidoscopy/colonoscopy. Imaging with plain films CT scan can also aid with diagnosis, especially complications such as toxic megacolon.

Diagnostic Tests & Interpretation

Labs/Studies

Complete blood count to assess for anemia hemoconcentration
Complete metabolic panel (electrolytes LFTs). BUN/Cr ratio of 20:1 may indicate dehydration, low bicarbonate values may indicate acidosis due to dehydration or infection.
Coagulation studies if liver disease is present
EKG
Type screen or type cross if anemia is present

CONCOMITANT ORGAN DYSFUNCTION

Extra-intestinal manifestations:

Eye: Episcleritis, uveitis, dry eyes
Liver: Jaundice, fluid retention, primary sclerosing cholangitis
Bone: Arthritis, including ankylosing spondylitis, can result in reduced flexibility, joint pain, reduce mobility. Metabolic bone disease can occur from chronic electrolyte abnormalities poor absorption of nutrients.
Hematologic: Autoimmune hemolytic anemia
Skin: Erythema nodosum (tender, red nodules that appear over the shins ankles as well as the arms) pyoderma gangrenosum (necrosis of skin leading to large ulcers)

Circumstances to delay/Conditions

Significant hypovolemia /or electrolyte disturbances
Severe anemia requiring blood transfusion

Classifications

Based on severity
- Mild
- Moderate
- Severe
Based on the extent of colonic involvement
- Proctitis (involvement of rectum only)
- Proctosigmoiditis (involvement of the rectum sigmoid colon)
- Left-sided colitis (involvement of the rectum colon up to the splenic flexure)
- Pancolitis (involvement of the entire colon)

Treatment ⬆ ⬇

PREOPERATIVE PREPARATION

Premedications

Anxiolysis as needed
Stress dose steroids should be considered if the patient has been treated for more than 2 weeks within the past 6–12 months to avoid manifestations of adrenal insufficiency. Steroids with glucocorticoid mineralocorticoid activity should be administered.

INTRAOPERATIVE CARE

Choice of Anesthesia

Epidurals for intraoperative (with or without GA) postoperative management should be considered for abdominal procedures. However, neuraxial blocks may be precluded with coagulopathy.

Monitors

Stard ASA monitors
Avoid rectal temperature monitoring
Foley catheter in long cases, suspected hypovolemia, or anticipated large fluid shifts
Arterial line may be considered in patients who are anemic, have baseline electrolyte abnormalities, brittle diabetes (from steroid use), or if the surgical procedure is anticipated to yield large blood loss.
Consider a central venous catheter for pressure monitoring guidance on fluid resuscitation.

Induction/Airway Management

In hypovolemic patients, consider adequate preoperative fluid hydration prior to induction.
Etomidate or ketamine can be useful in hypovolemic patients; have vasopressors available.
In anemic patients, consider having blood available or transfuse prior to induction.

Maintenance

Muscle relaxation can aid surgical exposure closure of abdominal fascia for bowel surgery.
Fluid management: Replace deficits with crystalloid. Be aware of replete insensible losses. Patients are at risk for significant third-spacing bowel edema, especially due to low colloid oncotic pressures. This can make closure of abdominal incisions more difficult.
Low albumin levels due to malnutrition: Adjust medication doses appropriately, particularly with highly protein-bound drugs. Unbound, free drug is pharmacologically active, is also available for metabolism. Thus consider smaller boluses more frequent dosing. Additionally, hypoalbuminemia may result in increased total body water volume of distribution for hydrophilic drugs.
Consider avoiding nitrous oxide for bowel surgery as it can cause the bowel to exp make fascial closure more difficult.
Diabetics may require intraoperative glucose management with insulin.
Intractable intraoperative hypotension may be due to adrenal insufficiency; treat with stress dose steroids.
Eye protection to avoid worsening ocular manifestations
Skin may be thin or easily breached from long-term steroid use; caution with positioning tape for IV sites, ETT, eyes

Extubation/Emergence

Reversal of nondepolarizing muscle relaxants can help minimize weakness as patients often have underlying weakness due to malnutrition electrolyte disturbances.

Follow-Up ⬆ ⬇

Bed Acuity

Telemetry if the patient has severe electrolyte derangements

Medications/Lab Studies/Consults

Consider an epidural or PCA for post-operative pain control with large incisions for colectomy.
Avoid ketorolac non-steroidal anti-inflammatory drugs due to metabolic bone disease.
Postoperative complete blood count (CBC).

Complications

Weakness, cardiac arrhythmias, hypo/hyperglycemia
Complications due to hyperalimentation include hypo/hyperglycemia, hyperchloremic metabolic acidosis, fluid overload, electrolyte abnormalities, renal hepatic dysfunction

References ⬆ ⬇

Loftus EV Jr . Clinical epidemiology of inflammatory bowel disease: Incidence, prevalence, environmental influences. Gastroenterology. 2004;126(6):1504–1517.
Kappelman MD , Rifas-Shiman SL , Kleinman K , et al. The prevalence geographic distribution of Crohn's disease ulcerative colitis in the United States. Clin Gastroenterol Hepatol. 2007;5(12):1424–1429.
Abraham C , Cho JH. Inflammatory bowel disease. N Eng J Med. 2009:361(21):2066–2078.
Baumgart DC , Carding SR. Inflammatory bowel disease: cause immunobiology. Lancet. 2007; 369(9573):1627–1640.

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