What is the risk of stump blowout in patients with ulcerative colitis (UC) or inflammatory bowel disease (IBD)?

From the Guidelines

Stump blow out in colitis patients is a serious complication that requires immediate surgical consultation and treatment with broad-spectrum antibiotics, fluid resuscitation, and pain management, with surgical intervention ranging from drainage of collections to revision of the stump. To manage this complication, it is essential to consider the patient's underlying condition, such as ulcerative colitis or Crohn's disease, and the extent of the disease. According to the ECCO guidelines on therapeutics in Crohn's disease: surgical treatment 1, patients with chronic inflammation of the large bowel are at an increased risk of development of colorectal cancer, and the risk of CRC in CD increases with longer disease duration, extent of colitis, a familial history of CRC, coexistent primary sclerosing cholangitis, and the degree and duration of inflammation.

Prevention strategies include maintaining adequate stump length (at least 15-20 cm), avoiding excessive tension on suture lines, and considering presurgical optimization with steroids (prednisone 40mg daily for 1-2 weeks) to reduce inflammation, as suggested by the guidelines for the management of inflammatory bowel disease in adults 1. Some key points to consider in the management of stump blow out in colitis patients include:

• Immediate surgical consultation is essential to manage the complication
• Treatment typically involves broad-spectrum antibiotics, fluid resuscitation, and pain management
• Surgical intervention may be necessary, ranging from drainage of collections to revision of the stump
• Prevention strategies include maintaining adequate stump length, avoiding excessive tension on suture lines, and considering presurgical optimization with steroids
• Patients with severe colitis, particularly those with ulcerative colitis or Crohn's disease, are at higher risk for this complication due to compromised tissue integrity from chronic inflammation, as reported in the WSES-AAST guidelines: management of inflammatory bowel disease in the emergency setting 1.

Post-operatively, regular monitoring of the stump via endoscopy and careful management of any ongoing inflammatory bowel disease with appropriate medications (such as mesalamine, biologics, or immunomodulators) can help prevent this serious complication that carries significant morbidity and potential mortality.

From the Research

Stump Blow Out in Colitis Patients

• Stump blow out is a severe complication that can occur in patients with colitis, particularly those undergoing subtotal colectomy for ulcerative colitis 2, 3, 4.
• The risk of stump blow out is a concern in the management of colitis patients, and various studies have investigated the optimal approach to preventing this complication 2, 3, 4.
• One study found that rectal washout with povidone iodine solution and saline can be an effective rescue treatment to avoid the need for opening the rectal stump to drain sepsis in patients with stump-related pelvic sepsis 2.
• Another study compared the outcomes of patients with the rectal remnant left subcutaneously versus those with the rectal remnant left intra-abdominally, and found that severe surgical complications were not related to the handling of the rectal remnant 4.
• However, leaving the rectal remnant subcutaneously was associated with local wound problems, and risk factors for severe complications included emergency surgery and preoperative medication with 5-aminosalicylic acid 4.
• A retrospective cohort study found that the frequency and severity of complications in patients with the rectal remnant left subcutaneously versus patients with the rectal remnant left intra-abdominally were comparable, and that the handling of the rectal stump did not affect severe morbidity after subtotal colectomy for ulcerative colitis 4.
• The optimal management of the closed defunctionalized large-bowel stump after laparoscopic total abdominal colectomy with end ileostomy for ulcerative colitis remains controversial, and further studies are needed to determine the best approach to preventing stump blow out 3.

Management of Stump Blow Out

• The management of stump blow out typically involves prompt surgical intervention to repair the stump and prevent further complications 2, 3, 4.
• In some cases, rectal washout with povidone iodine solution and saline may be used as a rescue treatment to avoid the need for opening the rectal stump to drain sepsis 2.
• The use of antibiotics and supportive care, such as bowel rest and fluid resuscitation, may also be necessary to manage stump blow out and prevent further complications 5, 6.

Prevention of Stump Blow Out

• The prevention of stump blow out is critical in the management of colitis patients, and various strategies can be used to reduce the risk of this complication 2, 3, 4.
• These strategies may include the use of rectal washout with povidone iodine solution and saline, leaving the rectal remnant intra-abdominally, and avoiding emergency surgery and preoperative medication with 5-aminosalicylic acid 2, 4.
• Further studies are needed to determine the most effective strategies for preventing stump blow out in colitis patients 3, 4.