intestine and reconnecting the healthy ends, ulcerative colitis can generally be cured by surgical removal of the large intestine. surgical removal of the large intestine will not get rid of extra-intestinal symptoms. this procedure is necessary in the event of exsanguinating hemorrhage, frank perforation, or documented or strongly suspected carcinoma. surgery is also indicated for patients with severe colitis or toxic megacolon. patients with symptoms that are disabling and do not respond to drugs may wish to consider whether surgery would improve the quality of life. depending on the type of surgery performed, the patient may still require periodic lower endoscopies to assess the pouch for dysplasia. ulcerative colitis is a disease that affects many parts of the body outside the intestinal tract. in rare cases the extra-intestinal manifestations of the disease may require removal of the colon. microbiome modification a cochrane review of controlled trials using various probiotics found low-certainty evidence that probiotic supplements may increase the probability of clinical remission. people receiving probiotics were 73% more likely to experience disease remission and over 2x as likely to report improvement in symptoms compared to those receiving a placebo, with no clear difference in minor or serious adverse effects. although there was no clear evidence of greater remission when probiotic supplements were compared with 5‐aminosalicylic acid treatment as a monotherapy, the likelihood of remission was 22% higher if probiotics were used in combination with 5-aminosalicylic acid therapy. it is currently is unclear whether probiotics help to prevent future relapse in people with stable disease activity, either as a monotherapy or combination therapy. alternative treatments dietary modification there is no good evidence that dietary interventions have any impact on ulcerative colitis. fats and oils fish oil, eicosapentaenoic acid (epa) is not conclusive. slow release phosphatidylcholine has some evidence of benefit in ulcerative colitis. antioxidants the free radical induction theory suggests that the initial cause of ulcerative colitis may be a metabolic defect that allows a buildup of chemicals related to hydrogen peroxide beneath the membrane that protects the cells of the intestinal wall from the bacteria inside the intestine, resulting in destruction of the membrane. during remission the membrane is reestablished, but may be subject to new damage, resulting in a flare up of the disease. to the extent this may be true, it would be appropriate to take antioxidants, dietary supplements that may support the body's defenses against oxidants like hydrogen peroxide. antioxidants include: vitamins a, c and e coenzyme q10 selenium and manganese. vitamin b6 and iron may be associated with increased hydrogen peroxide levels, and should not be taken in excess under this theory. s-methylmethionine has been shown in animal models to reverse ulcers. helminthic therapy inflammatory bowel disease is less common in the developing world and it has been suggested that this may be because intestinal parasites are more common in underdeveloped countries. some parasites are able to reduce the immune response of the intestine, an adaptation that helps the parasite colonize the intestine. a decrease in immune response could be helpful in inflammatory bowel disease. helminthic therapy using the whipworm trichuris suis was shown in a randomized control trial to produce benefit in patients with ulcerative colitis. this therapy tests the hygiene hypothesis which argues that the absence of helminths in the colons of patients in the western world may lead to inflammation. both helminthic therapy and fecal bacteriotherapy induce a characteristic th2 white cell response in the diseased areas, which is somewhat paradoxical given that ulcerative colitis immunology was thought to classically involve th2 overproduction.