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The decision for surgery may be made if medication does not bring the expected results. Usually the entire large intestine and rectum is removed but the anus is left and a pouch (so-called J-pouch) or an ileostomy is made. Other indications for surgery are fulminant colitis (sudden, severe inflammation), toxic megacolon (distension of the bowel) or bowel perforation, severe bleeding and anaplasias.

5–10 % of ulcerative colitis patients are operated within 10 years of the diagnosis. A third of ulcerative colitis patients in total are operated. It is always better that the surgery is pre-planned, and a good general condition and nutritional state promote recovery. It is recommended that the patient quits smoking before surgery, and alcohol should be consumed within limits.

When the surgery is pre-planned, a proctocolectomy (removal of large intestine and rectum) and J-pouch can be done in one surgery. Whether a temporary, protective ileostomy is needed will be decided on an individual basis. If the surgery is done as an emergency, the large intestine is usually removed, the anus left, and a temporary ileostomy built. J-pouch can usually be built in one or two further operations.

J-pouch or IPAA (Ileal Pouch Anal Anastomosis) is a container built of the small intestine. The large intestine is removed and cat above the sphincter muscles. A pouch sewn of the small intestine is attached to the end of the anal canal.

If the patient is in a very bad condition, old or very obese or the sphincter muscles do not function for some reason, a J-pouch cannot be made. Only rarely a J-pouch needs to be removed and a permanent ostomy made instead.

Usually the J-pouch works well and because the inflamed large intestine has been removed, medication is no longer needed. About a half of ulcerative colitis patients experiences complications after surgery, but most of them pass. Urgent problems include bleeding, failure of the suture line or infections.

The most common complication after surgery is pouchitis (inflammation of the J-pouch). Ten years after surgery, almost half of the patients have experienced at least one pouchitis. Its symptoms include diarrhea, bleeding and fever and it is treated mostly with antibiotics. The need for salt and fluids increases after J-pouch surgery, and the patient needs to drink enough and use enough salt.

J-pouch cannot be seen. The patient will need to defecate 4-9 times per day, but this improves when time passes. In about 80 % of operated patients, continence remains normal. There are exercise instructions for improving continence.

After the surgery, stools can be almost liquid. As time passes, the pouch starts to absorb more fluids and stools will become more solid. Diet can help in making the stools more solid. Diarrhea medicines can also be used, but their use should be started slowly.

Some patients have scarring in the anal area, which may make emptying the pouch difficult or cause incontinence. Scar tissue can be removed by operating or it can be stretched in endoscopy.

After removing the large intestine, the symptoms of co-morbidities usually disappear or become a great deal easier. However, there is no evidence of recovery from sclerosing cholangitis or ankylosing spondylitis. Joint symptoms usually subside and the bone mass, decreased by cortisone use, is somewhat repaired.

Having a surgery is often postponed because the patient is afraid of it and the possibility of an ostomy. Most patients think later, however, that they should have had surgery much earlier.