Surgical treatment

Considerable conflicting data have been published regarding complication rates following medical and surgical intervention in patients with indeterminate colitis versus ulcerative colitis. Some centers reported that indeterminate colitis was more refractory to medical interventions than ulcerative colitis, resulting in a greater relapse rate29 and subsequent need for colectomy.30 Colectomy rates averaged 36.1/1000 person-years in patients with indeterminate colitis versus only 7.5 for those with definite ulcerative colitis.30 In contrast, Witte et al described similar response rates to medical intervention in indeterminate colitis and ulcerative colitis.31 The European Collaborative Study on Inflammatory Bowel Disease (EC-IBD) reported 'complete relief of complaints' in 48% of ulcerative colitis patients versus 50% of those with indeterminate colitis; in addition, 37% of patients with ulcerative colitis 'improved' versus 33% with indeterminate colitis.31 Similarly, higher rates of pouch failure after ileal pouch-anal anastomosis (IPPA)32,33 and colorectal cancer34 have been reported by some groups, while others have reported lower rates of pouchitis for indeterminate colitis (29%) than ulcerative colitis (58%) and Crohn's disease (72%). However, this latter group observed a greater frequency of fistulae after IPAA in patients with indeterminate colitis (26%) versus for ulcerative colitis (10%).35 Post-IPAA complications resulting in pouch removal were higher for indeterminate colitis (19-28%) versus ulcerative colitis (0.4-8%) in some studies32,33 but not in others.35-37

It is our practice to repeat colonoscopy, usually with concurrent EGD, during selected periods of relapse to assess whether histological changes consistent with ulcerative colitis or Crohn's disease have developed. This is especially the case if colectomy and IPAA are being considered because of refractory disease. At this time, repeat small-bowel X-ray is usually obtained so that patients with ileal Crohn's disease would be excluded and patients with persistent indeterminate colitis would be counseled regarding the potentially greater risk of pouch complications. Often, patients with indeterminate colitis undergo a multi-staged operative procedure consisting of a subtotal colectomy with temporary ileostomy and Hartmann pouch. In this way, the entire resected colon can be assessed to exclude Crohn's disease prior to creating the IPAA.36

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