Ileorectal anastomosis in ulcerative colitis

Ileorectal Anastomosis in Ulcerative Colitis

Results in 27 Patients

CHARLES H. BROW~, M.D., RUPERT B. TURNBULL, JR., M.D., and ROBE~TO DIAZ, M.D.*

T Hr: PAST r z w DECADES have brought many changes in the surgical treatment of ulcerative colitis. At one time appendicostomy and cecostomy

were performed to permit antiseptics, such as Dakin's solution, and mercu- rial solutions, to be flushed through the inflamed colon. Later, ileostomy, to "put the colon at rest '"by divert ing the fecal stream, was preferred. When many patients continued to have active disease in the colon and acute toxic flareups of ulcerative colitis despite ileostomy, most surgeons advised that after ileostomy colectomy be performed when the pat ient 's condit ion had improved. However, many patients waited for fur ther surgery until an acute toxic flareup had occurred, and such operations had a high mortali ty. / leostomy alone in the pat ient in an acutely toxic condit ion was found to have a high mor ta l i ty - -o f 2'4-66 per cenO, ~ or more. From the reports of results of ileostomy alone for ulcerative colitis it became evident that this operation did not "put the colon at rest," cure the disease, or prevent sub- sequent complications and acute flareups. We observed that carcinomas developed in patients with ileostomies; and in one patient, a carcinoma actually extended through the ileostomy stoma, z

T h e next improvement in surgical therapy for ulcerative colitis was the practice of per forming ileostomy and subtotal colectorny at the same time in the pat ient in an acutely toxic condition. Ferguson and Stevens 4 stated: " T h e patients are too sick not to be operated upon." Crile and Thomas -° stated: "Removal of the colon, as completely, and as quickly as possible, ap- pears to be the safest method of treat ing patients with acute toxic ulcerative colitis." Crile and T h o m a s -° reported one death in 7 such patients sub- jeered to subtotal colectomy, an improvement over the morta l i ty in patients receiving medical t reatment for the condit ion and an improvement over the mortal i ty in those treated surgically by ileostomy alone.

From the Department of Gastroenterology and the Department of General Surgery, q-he Cleveland Clinic Foundation. and The Frank E. Bunts Educational Institute, Cleve- land, Ohio.

The authors wish to acknowledge the technical assistance of Mrs. Norma Gill, En- terostomal Therapist.

*Special Fellow, Department of Gastroenterology.

~ H)fi2 b~ HOEBER MEm¢ ~l. l')tvlsloY Or HARPER ~ ROW, Publ ishers , New York.

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Brown ef al.

Various teclmics a, ~ of improving the ileostomy, including the skin- grafted ileostomy, the mucosal-grafted ileostomy, and the mucosal-everted ileostomy resulted in fewer complications from the ileostomy. Turnbul l , 7 and Crite and T u r n b u l l s found that by covering the serosa, serositis was avoided and dysfunction was eliminated.

T h e latest improvement in surgical technic for ulcerative colitis has been the at tempt to restore intestinal continuity (Fig. 1). Since ileostomy was first used, some patients have wished and demanded restoration of intestinal continuity. We found* that, in 6 patients who demanded that the ileostomy be taken down, 3 developed further colitis and succumbed to the disease, a mortal i ty of 50 per cent. Attempts at anastomosing the ileum to the sigmoid colon after subtotal colectomy have generally failed, with recurrent colitis in the retained colon.

Fig. I . Barimn study of ileorectal anastomosis. T h e suture

line (arrow) is 11 cm. above the a n t i s .

Aylett 9, 10 has worked extensively on the ileorectal anastomosis. He believes that the success of this procedure depends on the removal of the colon, sigmoid colon, and the uppermost port ion of the rectum. He noted that the diseased rectum healed following such a procedure. Aylett also noted that with the diffuse form of the disease, minimal involvement of the ampulla of the rectum occurred while the areas immediately above (recto- sigmoid and sigmoid colon) were the most ulcerated and most frequently involved with pseudopolyps.

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Devine and Devine xt of Australia were among the first to advise ileorectal anastomosis in ulcerative colitis. Wangensteen and T o o n x2 in 1948 reported on 13 patients, only 2 of whom had diffuse colitis, in whom anastomosis to the sigmoid colon or rectum was done. They obtained satisfactory results in the 13 patients and noted healing of the rectal lesions in the 2 patients with diffuse ulcerative colitis.

Corbett and O'I)ell, xa at St. Bartholomew's Hospital in the period from 1949 to 1956, operated upon 56 patients with ulcerative colitis; ileorectal anastomoses were performed in 17. They believe that ileorectal anastomosis should be reserved for those patients who have minimal involvement of the rectum and sigmoid colon. Goligher, 1~ report ing on 22 patients subjected to anastomosis, obtained excellent results in patients with segmental colitis, but poor results (failures in more than half of the cases) in those with the diffuse form of ulcerative colitis.

Ungtey, 15 at T h e Gordon Hospital, London, England, reported that among 700 patients having ulcerative colitis, 175 have been treated surgically, and that removal of the rectum was necessary in only 7 cases. T h e author believes the severely diseased rectum heals after colectomy.

Aylet06 has been the chief proponent of ileorectal anastomosis, and has the largest series of cases. In 1960, he reported 131 patients subjected to this procedure, with a postoperative mortali ty of 5.4 per cent (7 patients). Four patients subsequently required permanent ileostomy, 2 because of incontinence and 2 because of rectal fistulas. Of 118 patients with a min imum follow-up of 6 months, 106 (90 per cent) have been restored to health. T h e number of bowel movements per day was 6 or less in 94 (80 per cent) of the patients. Aylett reports that the rectum heals after colectomy and ileorectal anastomosis, even when there has been severe disease previously.

In the United States, there has been little enthusiasm for establishing intestinal continuity or for ileorectal anastomosis, and there have been few reported series. The first report was by Wangensteen and T o o n 12 in 1948. They obtained good results with an anastomotic procedure (site of anastomosis not stated) in 13 patients with ulcerative colitis, 11 of whom had the segmental type of colitis. Of 30 patients who underwent this procedure at the Mayo Clinic, 1~ (site of anastomosis not stated) follow-up studies were obtained in 25. One pat ient had died and 2 had undergone permanent ileostomy at another hospital. Of the remaining 22 patients, 21 gained weight and 20 had control of bowel movements. Mayo and Broders ~7 state "there are instances, ahhough rare, in which abdominal colectomy with ileoproctostomy is a justifiable procedure in cases of ulcerative colitis." They believed that the operat ion should not be done if there were more than minimal involvement of the rectum.

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Fallis and Barron ~ reported 20 patients with ulcerative colitis who underwent a loop type of ileorectal anastomosis. Fifteen of the operations were performed in one stage and 5 in two stages. One patient died 9 months after operation, following multiple intraabdominal abscesses, ileal and jejunal ulcerations, and hemorrhage. None of the patients has reqttired an ileostomy. In 4 patients further disease that respondetl to medical treatment developed in the rectum, while in 2, fistulas developed which responded to surgical treatment.

There are extreme differences of opinion concerning ileorectal anastomosis, varying from the enthusiastic use of the procedure by Aylett, in :dl patients subjected to surgery, to the complete rejection of the procedure by most American surgeons, e~en in patients with segmental colitis. Turn- bulU.m 2o has presented a preliminary report on the first 14 patients subjected to ileorectal anastomosis at the Cleveland Clinic, and we believe further evaluation of our results in 27 patients, with a longer follow-up, to be worlhwhile.

M A T E R I A L

Twenty-seven patients have been subjected to subtotal colectomy and ileorectal anastomosis. Of these, 21 were female and 6 were male. We believe that the sex ratio of those subjected to ileorectat anastomosis is significant. Women, usually more fastidious than men, may not tolerate iteostomy as well attd may demand a "hook-up" procedure more freqttently. The distribution of patients according to age was as follows.

Age (y~.) No. o[ patients

0-10 0 11-20 l 21-3O I 1 31-4O 4 41-50 4 51-60 3 6 1 - 7 o 1

We believe that surgery is a last resort for pat ien t s w i th ulcerat ive colitis,

and every attempt at medical management was tnade before surgical in- tervention as may be seen in the following list of indications for colectotnx' (first operation) :

Indications

Acute. toxic, fuhninating, ulcerative colitis (with other complications: 5) Persistent symptoms despite medical therapy Persistent s)mptoms and s~stemic complications Ancnlia

No. o[ patients

13 7 3 2


Ileorectal Anastomosis

Among the complications were the impression of impending perfora t ion in 4 patients and actual perforat ion of the bowel in 2. Five of the patients had the systemic complicat ion of rheumato id arthritis and 2 had pyoderma gangrenosum. T h e durat ion of symptoms of ulcerative colitis before the operat ion was as follows.

Duration No. o] patien Is

(~-5.9 mo. 6 6-11.9 mo. 2 I-1.9 yr. 6 2-2.9 yr. 4 3-3.9 yr. 2 4-4.9 ~r. 2 Over 5 yr. 5

In 7 of the 27 patients ileorectal anastomosis was done as a pr imary procedure; these 7 patients had minimal or no involvement of the rectum. T h e remaining 2{) patients underwent the ileorectal anastomosis as a secondary procedure following a previous ileostomy or ileostomy with subtotal colectomy. The length of time between the pr imary procedure and the ileorectal anastomosis ranged from less than one year in 3 patients to 18 years in one pat ient who had previously had an exclusion ileostomy. "/'he interval between the two operations in the remaining patients was 1-2 )'ears in 8 patients, 2-3 years in 4 patients, 3-4 )ears in one patient, and 6-7 )ears in 2 patients. The re was no postoperat ive morta l i ty in the 27 patients.

T h e degree of involvement of the rectum before operat ion is most impor tant (Table 1). One would expect that the results of ileorectal anastomosis would be better in patients who had the segmental type of ulcerative colitis with no involvement of the rectum than in those patients who had severe disease in the rectum. Many surgeons have l imited ileorectal anasto-

TABLI!'. I. STATUS OF RECTtTM BEFORE ILEORECTAL ANASTOMOSIS

No. of patient*

Before Before coleclomy and ileostomy ileorectal

Status (lst stage) anastomosis

No discasc 1 7 Healed 0 9 Minimal disease 3 8 Moderate disease 12 3 No preliminary colectomy 7 0 Colectomy and ileostomy at another hospital 4 0

TOTAL 27 27


Brown et al.

mosis to those patients who have not had any disease in the rectum, although Aylett 16 uses the procedure in most of his patients, regardless of the severity of the rectal disease, and reports healing of the rectal mucosa following surgery. Figure 2 shows a diseased rectum in which anastomosis would have been possible.

Three patients had anorectal complications of ulcerative colitis; one had a fissure, abscess, and a sentinel hemorrhoid; one had a fissure and a large ulcer; and the third had an anal fistula. Seven patients had the "segmental type" of ulcerative colitis with no evidence of disease in the rectum. This type may be considered to be ideal for ileorectal anastomosis.

T h e majori ty of the patients with moderate disease in the rectum origi- nally had either minimal or healed ulcerative colitis at the time of the ileorectal anastomosis (17 pat ients) . T h e previous operation (almost al- ways subtotal colectomy and ileostomy) had improved the rectal disease before the anastomosis was attempted. However, 3 patients did have mod- erately active disease at the time of anastomosis, but had no difficulty with healing of the suture line. Twelve patients had moderate disease o1~ the rectum prior to colectomy. T h e improvement in the rectal disease following colectomy supports Aylett's view that the main site of involvement is the sigmoid colon and that the rectum may be involved secondary to the seepage of pus from the sigmoid. Cessation of the contaminat ion of the rectal mucosa from above as a result of colectomy may result in healing of the rectum.

T h e indications for anastomosis were mostly the wishes and strong de- sires of the patients. Some patients have a tremendous desire to be "nor- mal," and 2 claimed they would commit suicide if they were not "hooked- u p , ~

One patient with mild psoriasis had a severe Koebner's phenomenon 2~

Fig. 2. To ta l proctocolectomy for ulcerat ive colitis. R e c t u m (lower le[t) is diseased bu t not

de fo rmed : Pseudopolyps and s t r ic ture (arrow) are typically located al 11 cm. llex)rectal anastomosis below the de fo rming disease would have been possible.


tleorec÷al Anastomosis

caused by tile iteostomy, with not only an acute fiareup of tile psoriasis over the abdomen, but also over other parts of the body, including the scalp and vulva, i t was fortunate that this pat ient still had the rectum so that an anastomosis could be done, with resultant relief of the Koebner 's reaction and psoriasis. With the exception of this one case, there were no serious organic lesions that necessitated the anastomotic operation.

T h e length of follow-up of any study on colitis is most important . T h e problem of recurrent disease or the possible development of carcinoma in the rectal segment requires a tong period of observation to evaluate. Our follow-up period is insufficient to answer many of these questions:

Follow-up No. of patients

Less than 6 too. 4 6-11.9 too. .'3 1-1.9 yr. 3 2-2.9 yr. 4 3-3.9 yr. 7 4-4.9 yr. 4 Over 5 )r. 2

RESULTS

Of tile 27 patients, 23 have been observed for from 6 months to more than 5 years, and 4 have been followed for less than 6 months. T o date, the latter 4 patients are making satisfactory progress.

It is difficult to analyze tile results and present them in a simple table. For example, tile results in 5 patients are tabulated as failures (not technical failures) 1 of tile procedure, although, following reconstruction of the ileostomy, tile patients' conditions are progressing satisfactorily (] 'able 2).

Of the 6 patients classified as failures, one again has an ileorectal anastomosis, and 2 others have temporal 3, ileostomies and may, with satisfactory progress, have re-establishment of intestinal continuity. All of the 6 are well and working after their fur ther surgery.

In 3 of the 6 patients with results classified as failures, massive bleeding from the rectum occurred (similar to bleeding from a peptic ulcer) that resulted in shock and required emergency operation. Strangely, in 2 of the 3 patients, there was ilo active disease noted in the rectal mucosa, but ra ther actual diapedesis of whole blood through what appeared to be intact mucosa. Removal of the rectum was done in 2 of these patients, while a temporary diverting ileostomy was done in the third. All three are making satisfactory progress.

Ileostomy was performed in the fourth because the patient was suffering from malnutr i t ion and showed an inability to gain weight. T h e fifth pa-

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TABLE 2. DATA ON FAILURE OFILEORECTALANAS'FOMOSISIN 6 PATIENTS

,~ro.

Operation Ca~tse o] ]allure o[ patients Present status

Removal of rectum and permanent ileostomy

Dive r t ing i leos tomy (temporary)

Dive r t ing i leos tomy (temporary)

D~'er tintg i leos tom S (permanent, but rec-

tum retained) Reresection of ileum

with a new ileorectal anastomosis

Massive h e m o r r h a g e 2 Well and working from rectal segment

,Massive h e m o r r h a g e 1 Welt and working; ileorec- from rectal segment tal anastomosis may be

done later Failure to gain weight l Anastomosis may he done

later Incor t t inence due to l

anal fistula

Terminal ileitis with 1 I leorecta l anastomosis perforation again established

tient had a fistula and loss of the anal sphincter before the ileorectal anastomosis. Following the procedure he had excess diarrhea and incontinence. Consequently, we believe that if there is severe involvement o[ the anal sphincter, ileorectal anastomosis should not be clone.

T h e sixth patient, a 32-year-old woman, developed regional ileitis with perforat ion following the original anastomosis. She had threatened suicide when she had an ileostomy before her first anastomosis, and she again threatened suicide unless intestinal cont inui ty were re-established. Conse- quently, resection of the ileum and a second ileorectal anastomosis were done.

One other patient, a t4-year-oht girt, developed terminal ileitis following colectomy and ileorectal anastomosis. This patient has responded to medical treatment and has been relatively well for the past 4 years. Re- gional enteritis after colectomy for ulcerative colit.is is becoming recognized as one of the complications of the disease that can follow surgery.

We would not expect regional enteritis to be more freqttem after ileorectal anastomosis than it is after ileostomy with subtotal colectomy. Turn- bull has found that, of 230 patients subjected to ileostomy with subtotal colectomy, regional enteritis developed in 15 patients who had no evidence of the disease at the time of surgery, and in 10 who had. ileocolitis of "back- wash" ileitis. Tols tedt and Bell 24 found fi'ank ulcerations of the ileum in 11 (34 per cent) of 40 patients subjected to colectomy for ulcerative colitis. Swinton 25 reported 10 patients, 5 of whom had no previous involvement of the small bowel, who developed regional enteritis after subtotal colectomy. This is a.real and serious complication of ulcerative colitis, whether the patient is treated medically or surgically.

592 American Journal of D;ges¢ive Diseases

tleorectM Anas¢omosis

TABLE 3. POSIOI'ERA'IIVE COMI'LICATIONS IN 7 PAFIENTS "~VITH ILEORECTAL ANASTOMOSIS

Complicatio~ No. of patients Comment

Ulcerative proctitis 3 Episodes of obstruction 2 Pelvic hematoma 1 l'eritonitis from spontaneous

perforation of jejmmjn 1 Leaking anastomosis 0

Responded to medical treatment Responded to medical treatment Responded to drainage

Responded to further smgery

There were other complications following ileorectal anastomosis, which responded to medical t reatment (Table 3). In 2 patients episodes of obstruction developed, and 3 patients have had recurrent ulcerative proctitis lhat has been treated medically, including the use of steroid re tent ion enemas 26 and Lomoti l ,* 27 the ant idiarrheal drug. Even if local disease recurs, it may still respond to adequate medical management . The re were no leaks in the anastomoses even in the patients with modera te disease in tile rectum, and no deaths.

Many of the patients required a period of adjus tment and adapta t ion to their anastomosis before the n u m b e r of bowel movements per day de- creased. For a period of al)proximately 6 months they required medical management of their diarrhea, including diet, ant idiarrheal drugs, such as Lomotil , and other measures.

T h e average n u m b e r of bowel movements per day in our series has been greater than that reported by Aylett. a6 T w o patients have 1-15 stools per clay. T h e remaining patients ei ther had too short a follow-up period to pro- vide significant data or required pe rmanen t ileostomy.

Of the 27 patients, there has been no postoperat ive mortali ty. Twenty- three are working, are housewives doing their full day's work, or are in college. Three patients have been pregnant , with successful delivery of 4 chihtren.

In some patients a l though there was no technical failure of the operation, over-all progress was not entirely satisfactory and other problems continued. For example, one pat ient obta ined excellent results f rom the ileorectal anastomosis, but his basic personali ty defect, which may have caused his ulcerative colitis, has now resulted in his becoming an alcoholic. Similar complications of a psychiatric nature have occurred in several other patients, a l though the technical results of the ileorectal anastomoses were excellent. One pat ient who demanded anastomosis a t t empted suicide 3 times, twice before anastomosis and once afterward, a l though how con-

*G. D. Searle & Co., Chicago, 111.

New Series, Vok 7, No. 7, t962 593

Brown et a/.

scientious the attempts were may be questionable. Another patient who a t tempted suicide has had narcotics addiction requiring treatment in Lex- ington, has been institutionalized several times because of schizoid behavior, and is under the constant care of a psychiatrist. Another patient is also a narcotics addict and, in addition, a sexual deviate with a history of molesting young boys and girls. The addiction and the sexual deviation were present before the ileorectal anastomosis. We 2-° have become more and more impressed with the high incidence of persistent emotional and behavior problems and personality defects in patients with ulcerative colitis. Colectomy may improve the emotional problem but the personality defect may persist in some cases; this does not mean that the operation is a failure.

QUESTIOXNAIRE

Occasionally the analysis of tile resuhs of operation may be affected by the personality and /o r the enthusiasm of the surgeon. In addition, a patient may be overawed by the surgeon or, fearful of another operation, may not admit that he does not feel completely well. In the hope of obtaining an impartial report, our ileostomy technician, who had an ileostomy her- self, wrote to each patient requesting an evaluation of his ileoproctostomy.

Of 25 patients who replied, all were enthusiastic about the "hook-up." Even the 5 patients who subsequently required ileostomy believed a trial with the iteoproctostomy to be worthwhile.

One pat ient stated that she felt like a new person and was now doing her own housework for the first t ime in many years. Another stated that she was as heahhy now as before her illness, and said she was the picture of heahh. The re were several comments that the "hook-up" made them a new person, and none wanted to re turn to the ileostomy. A nurse returned to work within 9 weeks after the ileoproctostomy and in addition did the family laundry, ironing, cooking, and baking. Tim enthusiasm of the patients concerning the ileoproctostomy was most convincing; many of the patients wrote with considerable eloquence.

DISCUSSION

We believe that ileorectal anastomosis should not be 'performed routine. ly in every pat ient requir ing surgery for ulcerative colitis. T h e operation is contraindicated when there has been destruction of the anal sphincter, severe disease of the anus, or severe disease of the rectum.

It is impor tant to realize that severe ulcerative proctitis in patients with ulcerative colitis who underwent subtotal colectomy may heal or improve

594 Amerlcan Journal of D;qestlve Diseases

lleorectnl Anastomosis

following operation and tur ther medical treatment. Local infusions into the rectal stump of hydrocortisone, sulfonamides, and antibiotics 26 may aid in healing; the same material can be administered in suppositories. Other general measures such as small doses of steriods orally, amine-oxidase in- hibitors, or Librium,* 27, 2s vitamins, and general nutr i t ional measures may help. Even the severely diseased rectum can heal sufficiently to permit an ileorectal anastomosis at a later date.

We believe it ilriportant that the rectum be spared and not routinely sacrificed in patients undergoing surgery for ulcerative colitis. T h e rectum should be removed only when there is destruction of the anal sphincter, or severe persistent disease following subtotal colectomy and despite medical treatment outl ined previously. One cannot forecast how well psycho- logically a patient will tolerate an ileostomy or whether or not some other condition may make resioration of intestinal cont inui ty advisable. Would the patients who threatened to commit suicide have accomplished this if their ileostomies were permanent? If ileorectal anastomosis could not have been accomplished in the patient with psoriasis and the severe Koebner 's phenomenon, her treatment would have been most difficult. In addition, medicines in the future may be even more effective in healing the rectum than those available today. Removal of the rectum permanent ly denies the patient any possibility of restoration of intestinal continuity. This is cer- tainly a responsibility that no surgeon can take lightly.

SUMMARY

1. Ileorectal anastomosis following cotectomy has been done in 27 pa- t i en t s - a s a primary procedure in 7 and a secondary procedure in 20. T h e r e was no postoperative mortality.

2. At the time of the ileorectal anastomosis, the majority of the patients had minimal, healed, or no disease in the rectum. Seven patients had segmental ulcerative colitis.

3. T h e durat ion of follow-up was more than 6 months in 22 patients and more than 3 years in 13.

4. T h e anastomosis had to be taken down and a temporary or permanent ileostomy established in 6 patients. Permanent ileostomy with resection of the rectum was done in 2. Resection of i leum and a new ileorectal anastomosis was done in one. A temporary divert ing ileostomy was done in 3, with the hope that later a new ileorectal anastomosis might be done. T h e trial on re-establishment of intestinal cont inui ty in no way injured these 6 patients, and their progress is satisfactory. If the ileorectal anastomosis

*Roche Lahoratories, Nutley, N. J.


Brown et ol.

fails to eradicate the disease, a temporary or permanent ileostomy can al- ways be done.

5. In 2 patients, terminal ileitis of the anastomosis developed, one patient requir ing fur ther surgery. Three patients with recurrent ulcerative proctitis responded to fur ther medical treatment.

6. Underlying personality and behavior problems (alcoholism, sexual deviation, schizoid reaction, and frank schizophrenia with several attempted suicides in one pat ient each, and narcotic addiction in 2 patients) were not altered by the operation.

7. T h e over-all results, including those in 6 patients who required ileostomy and who are completely rehabilitated, are excellent. Twenty-three of 27 have re turned to work or have assumed full duties as housewives, or are in college. Th ree patients have had successful pregnancies.

8. Letters from the patients to a person who had undergone colectomy with ileostomy (thus avoiding the bias that may affect a patient's report to his own doctor) were most enthusiastic about the results of ileorectat anastomosis.

9. We believe that ileorectal anastomosis should not be done routinely. T h e procedure should be restricted largely to those with minimal disease in the lower ampulla of the rectum and those with intact anal sphincters. Medical t reatment of the rectal stump may help to heal the rectal rnucosa after partial colectomy so that ileorectal anastomosis may later be done with successful results.

10. Removal of the rectum, which permanent ly prevents any re-establishment of intestinal continuity, should not be done unless the patient continues to have disease in the rectum, and symptoms, despite medical t reatment after partial colectomy.

2020 East 9~ St. Cleveland 6, Ohio

A D D E N D U M

Since preparat ion of this paper, the follow-np period has extended another 12 months with no fur ther failures. An additional 4 patients have undergone ileorectal anastomosis with good results.

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596 Arnerlaan Journal of Digestlve Diseases

Ileorecfal ,Anastomosis

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Ileorectal anastomosis in ulcerative colitis

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