Surgery in inflammatory bowel disease (IBD): ulcerative colitis

Written by: Professor Richard Cohen
Edited by: Emma McLeod

Ulcerative colitis (UC) is an inflammatory condition which affects the colon and causes symptoms such as mucous and bloody diarrhoea. Sometimes, medication isn’t enough to offer long-lasting relief from the condition. Professor Richard Cohen, a colorectal surgeon and expert in IBD, explains the surgical measures that can be provided to achieve an improved quality of life for people suffering from UC.

A young woman is sitting but hunched over. She is pressing on her abdominal area in discomfort.

Ulcerative colitis and its symptoms

Ulcerative Colitis (UC) is an inflammation of the lining (mucosa) of the bowel that affects a varying amount of the colon and rectum. Symptoms include bloody diarrhoea and passage of mucous when opening the bowels. Depending on how much of the bowel is affected and the degree of the inflammation, patients can vary from suffering a minor nuisance to being extremely unwell.


How is it treated?

UC is treated with anti-inflammatory medication including steroids, immunotherapy (azathioprine) and biological therapy. Patients are often managed by a multi-disciplinary team consisting of a surgeon, a gastroenterologist backed up by nurses, radiologists and pharmacists.


What role does surgery play in treating UC?

The role of surgery in the following categories of UC patients is as follows:

  • When the patient has severe acute colitis: Under these conditions, the colon may need to be removed as a matter of urgency to avoid perforation and peritonitis (inflammation of the peritoneum) if medication is not quickly effective.
  • When medical management has been unsuccessful: Under these circumstances, patients are chronically unwell despite maximal medical therapy
  • When the lining cells change towards malignancy (cancerous cells): This situation can arise in patients with total colitis who have had the disease for longer than a decade. Regular colonoscopic evaluation and biopsies may indicate that there is a change towards bowel cancer and the patient is best served by having the colon removed.


What surgical options are there?

There are various surgical options:

One option is the removal of the colon and rectum with and replacing it with a small bowel pouch reservoir (known as an ileoanal “pouch”). This procedure is often done in stages depending on how unwell the patient is at the time. The interval between the stages is usually three to six months.

  • Three stages
  1. Removal of the colon, leaving the rectum behind with an end ileostomy
  2. Removal of the rectum and the creation of a pouch with a loop ileostomy
  3. Reversal of the ileostomy


  • Two stages
  1. Removal of the colon and rectum with the creation of an ileoanal pouch with a loop ileostomy
  2. Reversal of ileostomy


  • One stage
  1. Removal of colon and rectum with the creation of an ileoanal pouch with no ileostomy


Another option is the removal of the colon, rectum and anal canal with a permanent ileostomy.


The decision regarding the best option is made between the surgeon, patient and gastroenterologist. Whilst nobody wants to have an ileostomy, it can be the safest way to manage the situation and is often a temporary safety measure.


Professor Richard Cohen is a leading London colorectal and general surgeon. Visit his profile to learn how he can help you with your colorectal health.

By Professor Richard Cohen
Colorectal surgery

Professor Richard Cohen is a leading colorectal and general surgeon based at the Cleveland Clinic in London. He is an expert on open and minimally-invasive laparoscopic colorectal surgery, colorectal cancer, and irritable bowel disease (IBD). Currently, Professor Cohen serves as a clinical professor of surgery, consultant surgeon, and honorary senior lecturer at University College London (UCL). He is renowned as a pioneer of introducing new techniques in the United Kingdom. 

After receiving his medical qualification from Combridge with distinction in 1987, Professor Cohen continued his training as a surgery registrar in Northwest England, and later as a senior registrar at Guy's and St Thomas' Hospital surgical training programme. Whilst undergoing his training, Professor Cohen also accomplished to carry out research at Yale University, USA, for his Master's thesis.

Professor Cohen joined UCL in 2005, where he has since helped to develop the colorectal service. Here and within his private practices, Professor Cohen maintains his expertise in open and minimally invasive colorectal surgery. Beyond his advanced surgery techniques, he focuses on colorectal cancer, benign colorectal disease, and management of ulcerative colitis, Crohn's disease, and IBD. He is a leading example for his practice fellows and other surgeons in his field.

Following his expertise in such subject, Professor Cohen continues to do research on topics of interest. These include pelvic floor disorders (incontinence and constipation), Crohn's disease, and colorectal cancer in Ashkenasi Jews. Research has persisted to be a passion of his, and subsequently he has had many papers published in peer-reviewed journals. Professor Cohen extends his involvement in colorectal surgery by also training young surgeons and lecturing nationally and internationally.

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