JSUR Journal

Table 1: Compares the reports found in the literature [3-9]. These are studies with 1 or more patients described, comparing them based on common factors, such as gender, age at onset of symptoms, clinic and treatment, as well as prognosis.

It is worth highlighting the scarce literature on patients suffering from UC after total proctocolectomy, as well as the similarity with the case presented in this article. In fact, the most important relationship seems to be found in the pattern of age and sex, since UC apparently affects a greater number of female patients, with 57.1% compared to males with 42.8%. Furthermore, it is inferred that younger women (under 30 years of age) are at greater risk of complications and the need for surgery, accounting for 42.8% of cases, while young men account for only 14.2%. However, as men age, their risk of UC increases to 28.5%, while women remain at 14.2%. Furthermore, factors such as earlier onset of symptoms culminated in more serious complications, requiring urgent surgery, such as a case similar to the one reported in this article, of a young woman with toxic megacolon. Regarding treatment, 71.4% of patients underwent total proctocolectomy and 100% had a good prognosis, with subsequent discharge and follow-up. However, no possible complications such as infections, wound dehiscence or ICU admission were reported

Discussion

Epidemiologically, some risk factors have been described, such as age, genetics, microbiota and diet. UC has a bimodal age distribution with a peak incidence in the second or third decades of life, followed by a second peak between 50-80 years of age. Around 8-14% of patients have a family history of inflammatory bowel disease and some markers such as the TNFSF15 (TL1A) locus, which increases the risk of UC with more serious complications, have been identified. It is assumed that the development of IBD is an immunological response to food. The Western-style diet is associated with an increased risk of developing UC, as well as increased intake of total fat, animal fat, and polyunsaturated fatty acids. Several studies point to dysbiosis of the intestinal microbiota in IBD, as this altered composition of commensal bacterial populations leads to dysregulation of the immune response to bacterial antigens [1]. Clinically, UC presents with bloody diarrhea, rectal urgency, tenesmus and varying degrees of abdominal pain, which is relieved after defecation. Typically, symptoms have intermittent attacks that can become more frequent and occasionally severe, which require hospitalization. The diagnosis depends on the aforementioned clinical features associated with histological findings on endoscopy and biopsy. Recent studies suggest that patients at higher risk of relapse are younger, with extensive disease, previous relapses, and fecal calprotectin greater than 190 ug/g on repeat tests [1]. Risk factors associated with increased disease extent include obesity, history of appendectomy, and severe disease activity. Over the years, many scoring systems have been developed to assess disease activity, such as the modified Riley score, the Gupta index, and the Geboes scoring system [10].

A feared complication in UC is toxic megacolon, in which the local inflammatory process can disrupt the neuromuscular function of the colon, leading to its dilation and subsequent perforation. TM is characterized by dilation of the colon (≥ 5-6 cm), along with signs of systemic toxicity, and is often associated with infectious colitis, which can lead to mortality if not treated [5]. The goals of treatment focus on improving quality of life, remission and minimizing the risk of cancer. The basic approach is based on severity, distribution, age of onset, duration of the disease, evolution, frequency of relapse, previous medication, medication side effects and extraintestinal manifestations. Severe acute ulcerative colitis is defined as six or more bloody bowel movements per day, associated with other systemic signs and symptoms. The therapeutic approach includes timely diagnosis and exclusion of enteric infections, with methylprednisolone 60 mg for 24 hours normally used as initial therapy. For patients who do not respond to corticosteroid therapy, we should consider colectomy in 3 to 5 days, as delays in surgery can significantly increase mortality. Other important points include fluid and electrolyte replacement, flexible sigmoidoscopy to rule out infections, stool cultures, nutritional support and DVT prophylaxis. The most commonly performed surgery is restorative proctocolectomy with ileal pouch-anal anastomosis [1,11].

Total proctocolectomy with anal anastomosis with ileal pouch represents the standard approach for patients with refractory UC or complications, including toxic megacolon. Studies show that early and late complications, mainly infections, can occur in more than 20% of patients, while long-term complications occur in less than 10% of patients [2]. However, proctocolectomy is associated with a significant improvement in patients’ quality of life. The exact moment to perform surgery in patients with moderate to severe UC still remains a challenge, but several factors must be considered and medication alternatives must be offered to patients without risk factors for complications. The impact of the disease on the patient’s quality of life, predictive factors of negative evolution and risk of side effects with medications must be taken into account. When both therapeutic options are valid, discussion with a multidisciplinary team is essential, balancing potential risks and benefits. The patient always needs to be well informed about the steps necessary to obtain a fully functional pouch, potential limitations and complications postoperatively and after restoration of intestinal flow [2,12].

Conclusion

Predicting the prognosis of patients with UC is very difficult, requiring individualization of the treatment plan and the same patient may require multiple modalities to achieve remission or improvement in quality of life. In summary, this is a rare presentation of ulcerative colitis in a young patient, without comorbidities or previous history, with rapid progression to perforated toxic megacolon. Fortunately, timely total proctocolectomy allowed for greater survival for the patient in question, as well as a better quality of life, even without adjuvant treatments.

References

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