Management of severe hemorrhage in ulcerative colitis

Twenty-five patients with ulcerative colitis were treated between 1959 and 1986 at The Mount Sinai Hospital, with severe gastrointestinal hemorrhage as their major complaint. Twenty-two patients required operation, while three patients were treated medically. Total proctocolectomy with ileostomy was carried out in 5 patients, and subtotal colectomy accompanied by mucous fistula (14), Hartmann closure (2), or ileosigmoidostomy (1) was performed in 17 patients. Eleven of the patients who underwent operation had emergency colectomies, while the remaining 11 had semielective procedures. Subtotal colectomy was performed in 10 of the 11 emergency cases. Indications for emergency surgery were massive hemorrhage alone in seven patients and severe hemorrhage complicated by toxic megacolon in four patients. One patient died postoperatively of a perforated duodenal ulcer following emergency subtotal colectomy. There were two late deaths from leukemia in one surgically treated patient and one medically treated patient at 9 and 18 months, respectively. All 4 of the 25 patients with remaining intact rectums were alive and well at 3- to 12-year follow-up. Subtotal colectomy can be undertaken in patients with massive hemorrhage from ulcerative colitis for whom subsequent ileoanal anastomosis is planned, provided that one recognizes and is prepared for the approximately 12% risk of continued rectal hemorrhage.
Ulcerative colitis, a chronic, inflammatory condition affecting the colon, leads to bloody diarrhea in most cases, but hemorrhage is rare. When it does occur, emergency surgery is necessary, and total proctocolectomy (removal of the colon and rectum) is often necessary. Subtotal colectomy (removal of the colon, leaving the rectum) may also be an effective way to treat colitis patients with hemorrhage. This was evaluated by reviewing records from 26 patients, who were either admitted with hemorrhage or who developed one. The average age at the onset of colitis was 25.4 years, and at the time of hemorrhage, 28 years. One patient in the group died due to infection following a perforated duodenal (small intestine) ulcer, and three were managed without surgery. Of the remaining 22 patients, emergency surgery was performed for 11, and 11 underwent semi-elective procedures. Total proctocolectomy was performed on five patients, with ileostomy (surgical creation of an opening through which the intestinal contents drain) for four, and ileo-anal anastomosis (connection of the small intestine to the anus) for one. The remaining 17 patients had subtotal procedures, most of which were done on an emergency basis. Of the patients with subtotal colectomy, 14 required subsequent surgery; seven of these procedures were planned at the time of the first operation. The four patients with intact rectums were alive and well at follow-up. Overall, it appears that subtotal colectomy can be performed in ulcerative colitis patients with massive hemorrhage when subsequent ileo-anal anastomosis is planned. The risk of continued rectal hemorrhage, however, is approximately 12 percent. (Consumer Summary produced by Reliance Medical Information, Inc.)