Living with Inflammatory Bowel Disease: When Medication Isn’t Enough

Inflammatory bowel disease (IBD) — primarily Crohn's disease and ulcerative colitis — is first and foremost managed by a gastroenterologist with medication. But for a meaningful number of patients, medication alone isn't enough to control the disease, and that's where a colorectal surgeon becomes part of the care team.

Medical Management Comes First

Modern IBD treatment includes anti-inflammatory medications, immune-modulating drugs, and biologic therapies that have significantly changed outcomes over the past two decades. For many patients, these medications achieve and maintain remission. Surgery is not typically the first option — it's considered when medical therapy isn't achieving adequate control, or when specific complications develop.

When Surgery Becomes Part of the Conversation

For ulcerative colitis: Surgery — removing the colon, and often the rectum — is considered when medications no longer control symptoms, or for complications like severe bleeding, a colon that stops functioning properly (toxic megacolon), perforation, or precancerous changes found on surveillance colonoscopy. Unlike Crohn's, removing the colon and rectum can be curative for ulcerative colitis, since the disease is limited to that part of the digestive tract.

For Crohn's disease: Because Crohn's can affect any part of the GI tract and tends to recur even after surgery, surgical treatment is more targeted — addressing specific complications like strictures (narrowing that causes blockages), fistulas (abnormal connections between the bowel and other structures), or abscesses, rather than attempting to remove all affected tissue.

What Patients Often Don't Realize

• Surgery for ulcerative colitis can mean the end of needing colitis medications entirely, since the diseased organ is removed.
• Many patients who need their colon removed are candidates for J pouch surgery, which avoids a permanent external ostomy for most people.
• Crohn's surgery is about treating a specific problem, not "curing" the underlying disease — ongoing medical management typically continues afterward.
• Minimally invasive techniques are used for many IBD surgeries today, which has meaningfully improved recovery compared to older open approaches.

A Team Decision

The decision to move from medical management to surgery is rarely made by one doctor alone. It typically involves your gastroenterologist, who has been managing your disease, and a colorectal surgeon, who can explain what surgery would actually involve and what to expect afterward — together with you, since you're the one living with the decision.