Ulcerative Colitis

Ulcerative Colitis
mucosal disease that usually involves the rectum and
extends proximally to involve all or part of the colon.
4050% of patients have disease limited to the rectum and
rectosigmoid
3040% have disease extending beyond the sigmoid but not
involving the whole colon
20% have a total colitis
When the whole colon is involved, the inflammation
extends 12 cm into the terminal ileum in 1020% of
patients.
This is called backwash ileitis.
With mild inflammation the mucosa is erythematous and
has a fine granular surface that looks like sandpaper.
 Pan-ulcerative
colitis. Mucosa has
a lumpy, bumpy
appearance
because of areas of
inflamed but intact
mucosa separated
by ulcerated areas
 Microscopic Features
of UC
1. Crypt architecture of the colon is distorted;
crypts may be bifid (divided into 2 equal parts)
and reduced in number, often with a gap
between the crypt bases and the muscularis
mucosae.
2. Mucosal vascular congestion, with edema and
focal hemorrhage, and an inflammatory cell
infiltrate of neutrophils, lymphocytes, plasma
cells, and macrophages may be present. The
neutrophils invade the epithelium, usually in the
crypts, giving rise to cryptitis and, ultimately, to
crypt abscesses (pus filled).
 Major symptoms
of UC
1. Diarrhea
often nocturnal and/or postprandial (after a meal)
2. rectal bleeding
blood is usually mixed with stool or grossly bloody diarrhea
3. tenesmus or urgency with a felling of incomplete
evacuation
4. passage of mucus
5. crampy abdominal pain
some patients with active disease may experience vague lower
abdominal discomfort or mild central abdominal cramping
severe cramping and abdominal pain can occur with severe
attacks of the disease
 Major symptoms
of UC
Patients with proctitis (rectal inflammation)
usually pass fresh blood or blood-stained
mucus, either mixed with stool or streaked onto
the surface of a normal or hard stool.
Colonic motility is altered by inflammation with
rapid transit through the inflamed intestine.
-Other symptoms in moderate to severe disease
include anorexia, nausea, vomiting, fever, and
weight loss.
 Physical Examination
Signs of proctitis include a tender anal
canal and blood on rectal examination.
With more extensive disease, patients
have tenderness to palpation directly over
the colon.
Patients with a toxic colitis have severe
pain and bleeding, and those with
megacolon have hepatic tympany.
 Classification of UC
Mild Moderate Severe

Bowel <4 per day 46 per day >6 per day

movements
Blood in Small Moderate Severe
stool
Fever None <37.5C >37.5C
mean mean
Tachycardia None <90 mean >90 mean
pulse pulse
Anemia Mild >75% 75%
Endoscopic appearance
Mild UC Erythema, decreased vascular
pattern, fine granularity
Moderate UC Marked erythema, coarse
granularity, absent vascular markings, contact
bleeding, no ulcerations
Severe UC Spontaneous bleeding,
ulcerations

***Sigmoidoscopy and Colonoscopy to

assess disease activity and is often performed
before treatment.
 Laboratory findings
Active disease
rise in acute-phase reactants [C-reactive
protein (CRP)]
rise in platelet count
rise in erythrocyte sedimentation rate (ESR)
decrease in hemoglobin.
In severely ill patients
serum albumin level fall
leukocytosis may be present
 Radiologic change of UC
(single-contrast barium enema)
fine mucosal granularity on early stages
with increasing severity
the mucosa becomes thickened, and superficial
ulcers are seen
Deep ulcerations can appear as "collar-button"
ulcers, which indicate that the ulceration has
penetrated the mucosa.
Loss of haustration can occur, especially in
patients with long-standing disease.
The colon becomes shortened and narrowed.
 Barium enema
in a patient with
acute ulcerative
colitis:
inflammation of
the entire colon.
 Complications
Only 15% of patients with UC present initially
with catastrophic (life threatening) illness.
Massive hemorrhage occurs with severe attacks
of disease in 1% of patients.
However, if a patient requires 68 units of blood
within 2448 h, colectomy is indicated.
About 50% of acute dilations will resolve with
medical therapy alone, but urgent colectomy is
required for those that do not improve.
 Complications
Toxic megacolon
transverse colon has a diameter of >56
cm, with loss of haustration
patients with severe attacks of UC
It occurs in about 5% of attacks and can
be triggered by electrolyte abnormalities
and narcotics.
 Complications
Perforation (formation of hole) is the most dangerous of
the local complications, and the physical signs of
peritonitis may not be obvious, especially if the patient is
receiving glucocorticoids.
Rare
mortality rate complicating a toxic megacolon is about 15%
Strictures (constrictions of body passages) occur in 5
10% of patients and are always a concern in UC
because of the possibility of underlying neoplasia.
A stricture that prevents passage of the colonoscope is an
indication for surgery.
 Treatment
Mild to Moderate UC
Sulfasalazine and other 5-ASA preparations
Role in remission maintenance
Sulfasalazine deliver both antibacterial
(sulfapyridine) and anti-inflammatory (5-ASA)
 Treatment
Moderate to Severe UC
Glucocorticoids
Prednisone (40-60 mg/d) oral
Hydrocortisone (300 mg/d)
Methylprednisolone (40-60 mg/d) IV
 Surgery in UC
INDICATIONS
Intractable disease
Toxic megacolon
Colonic perforation
Massive colonic hemorrhage
Extracolonic disease
Colonic obstruction
Colon cancer prophylaxis
Colon dysplasia or cancer