Treatment

• Choose medical therapy based on disease severity and disease extent.

• If remission is achieved, initiate maintenance therapy.

  • Continue the treatment used to achieve remission, with the exception of corticosteroids.

• If remission is not achieved, escalate treatment.

• Consult surgery for consideration of curative proctocolectomy if medical therapy is unsuccessful or complications occur.

• Screen for colorectal cancer and other common comorbidities (e.g., depression and anxiety).

• Pharmacological therapy is used to induce and maintain disease remission.

• Goals of treatment

  • Initially: symptomatic remission

  • Long-term: mucosal healing

• Treat pain as needed.

  • Nonpharmacological measures, e.g., heating pads

  • Consider acetaminophen, anxiolytics, and sedatives.

  • Avoid opioids and NSAIDs.

• Avoid parenteral nutrition unless required to improve nutritional status prior to colectomy.

• Identify and treat any micronutrient deficiency.

Ulcerative colitis can be cured surgically. Surgical treatment also reduces the risk of colorectal cancer.

• Indications

  • Complications of ASUC

    • Toxic megacolon

    • Bowel perforation

    • Multiorgan failure

    • Severe hematochezia

  • Refractory ulcerative colitis (i.e., no response after 3–5 days of medical management and/or corticosteroid dependence)

  • Dysplasia or carcinoma

• Procedure: restorative proctocolectomy with an ileal pouch-anal anastomosis (IPAA or J pouch)

  • Resection of the entire colon and rectal mucosa while sparing the anal sphincters.

  • Loops of small intestine (serving as the pouch) are used to create an artificial rectum, resulting in a continence-conserving connection between the ileum and anus.

• Complications of surgery

  • Early (≤ 30 days): anastomotic leak, pelvic sepsis

  • Late: bowel stricture, bowel obstruction, fertility issues, sexual dysfunction [4]

  • Most common late postoperative issue: pouchitis (increased stool frequency, malaise, and possibly incontinence caused by bacterial overgrowth)

• Colorectal cancer screening [2][24]

  • Start screening 8–10 years after the initial diagnosis or at the time of diagnosis of PSC.

    • Modality: ileocolonoscopy with biopsies

    • Interval: every 1–5 years