1. Ulcerative colitis
Its chronic inflammation of the colonic mucosa and rectum, can affect both male and female mostly between 20 to 40 years of age.
Etiology:
1- mucosal immunological reaction
2- weakened mucosal barrier
3-Defect in the metabolism of butyrate.
Pathology:
90% the rectum is involved, the disease spread proximally to various limit, its involves the mucosa and sub mucosa, there is no skip lesion and no macular involvement.

2. Macroscopically there is multiple superficial ulcerations with hyperemia and congested mucosa later there may be pseudopolyposis formation.
Microscopically there are lymphocytes infiltration with crypt abscess and decrease of goblet cell mucine, later there is dysplastic changes

3. Clinically the disease divided into 4 grades mild form: less than 4 times bloody diarrhea per day with out systemic picture. Moderate form more than 4 times bloody diarrhea per day with out systemic picture. Sever form more than 4 times bloody diarrhea per day with systemic picture inform of fever, malaise, tachycardia, anemia and hypoprotenaimia. Complicated form fulmenant attack, toxic dilatation, bleeding and perforation of colon.
Extra colonic manifestation:
Liver and biliary: colengitis, colangio ca
Eye: iritis
Joint: poly arthritis.
Skin: pyoderma gangerenosum, erythema nodosum and apthus ulceration.

4. Investigation: 1- barium enema
Investigation: 1- barium enema. 2-Sigmodoscopy and colonoscopy with biopsy. 3-nonspeciphic investigation.
Treatment
Medical treatment
Mild and moderate attack: steroid 40 mg /day with sulfasalzine 1gm/three times a day for 3 weeks
Sever form need admission to hospital for
1-resusetation of circulation and electrrolyte
2- paranteral hydrocortisone 100mg 4 times a day.
3- rectal steroid enema.
4- 5 ASA either sulfasalzine, masalazine, olsalazine,
5- immune suppressant agent may be used

5. Indication of surgery: 1- fulmenent disease not respond to medication 2- chronic illness with disability 3- steroid dependent 4- risk of neoplasia 5- extra colonic manifestation 6- complication inform of bleeding, toxic colon, perforation or obstruction.
Types of surgery used
1- total proctocolectomy with permanent ileostomy
2- total proctocolectomy with ileonalal anastomosis.
3- total colectomy with ileorectal anastomosis (not recommended)

6. Case 32 year old male from mosul married presented with sever bloody diarrhea of one month duration.
His history dated back to 4 months were he was admitted to the emergency department complaining of sever abdominal pain and vomiting with raped abdominal distension and absolute constipation of 2 days duration associated with fever and generalized ill health.
Diagnosis : volvolus of the sigmoid colon
Laparotomy done to him, the surgeon on duty found a gangrenous sigmoid colon with huge distension of the colon. A paul-mickuliks operation done to him.
Post operatively the patient developed sever bleeding from the stoma site that necessitate refashioning of the stoma, but the bleeding didn’t stopped.
The patient received 30 blood unites during a period of 5 days where the bleeding stopped.

7. The patient continuo to have diarrhea for the next two months and treated by metronidazole and antidiarrhea medication The surgeon decided to close the colostomy and he did that.. Post closer the patient develop bloody diarrhea more than 4 time per a day with tenesmus and colicky abdominal pain, intermittent fever, anorexia and loss of wt.
Review of systems:
Patient had palpitation and dyspnoea on exertion, no cough or sputum, normal urination, poly arthralgia, headache, dizziness and sleeplessness.
Past surgical and medical history: Repeated bouts of mild diarrhea between time and another for one year.
Previous operation for Lt renal stone when he was 6 years old.
Social and family history: Married, 2 kids, no same condition in the family.

8. Examination reveled: young age male cachexic, depressed and in pain, he was anemic, but not jaundiced or cyanosed with mild bilateral leg edema. PR 90 b\m regular with thready volume. BP 110/60 mm-hg RR 20/m regular temp 38.2 c
Abdominal examination
Extended midline and longitudinal left iliac fossae ,Lt Moreson scars.
Little bit distended abdomen, no visible mass or peristalses.
The abdomen was soft with tenderness at left ileac and suprapubic areas.
Percussion showed hyper resonance at epigastric ,left hypochonderial and left iliac areas.
Osculation showed excessive bowel sound.
PR reveled tenderness with bloody loose stool.

9. Investigation HB:8 gm/1ooml B UREA 60mg/1ooml total serum protein 4
Investigation HB:8 gm/1ooml B UREA 60mg/1ooml total serum protein 4.5 gm/l Liver function test: normal. FBS 126 mg/100ml
Barium enema showed: dilated left colon with loss of houstration.
Sigmoidoscopy showed sever and extensive ulceration of the rectum with pseudopolyposis,
Histology of punch biopsy showed class 4 ulcerative colitis.

10. Diagnosis : sever form of ulcerative colitis with complication of bleeding and possibility of previous toxic mega colon with extra colonic manifestation.
Management: patient admitted to hospital
1- parantiral nutrition through CVL in form of
Hypertonic 5O% two times a day
Intralipid 5OO cc between day and another
Vamin(AA) 500 cc two times day
Albumen 2 units per day
2- cephotoxim with metrondazole IV
3- two pints of blood transfusion.
4- salazopyren 1 gm three times a day.
The patient did well regarding his cardiovascular state but continuo having sever bloody diarrhea with abdominal distension.
The decision for surgical intervention was taken after discussion with the patient and his family the possible types of operation, there benefits and complications.

11. THE PROCEDURES USED are 1- total proctocolectomy
The operation done on 19/3/2009 at 10 AM under GA muscle relaxant, ETI,NG tube, folyes catheter, lithotomy position and midline incision
THE PROCEDURES USED are
1- total proctocolectomy
2- J shape ileal pouch (park)
3- ileo anal anastomosis.
4- protective iliostomy

14. The complications associated with ileoanal anastomosis are: pouchitis in 10% - 15%, surgical pelvic or wound infections 10–20%, anastomosis failure 5–10%. The advantage is to hove cotenant stool and avoid ileostomy
The patient received 6 pints of blood intra operatively and underwent uneventful recovery.
The patient now in his 6th post operative day
The vital signs are now stable
The ilostomy start working, he passed flatus and mucus secretion from the anus.
Abdomen is soft
Start oral feeding
Ultrasound of abdomen is normal
The patient is abut to discharge home
I hope to close the ileostomy after 2 or 3 months.