Ulcerative Colitis

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Ulcerative Colitis

• Katherine Doerr

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Definition

• An inflammatory bowel disease with recurring
  episodes of mucosal inflammation involving the
  rectum and extending proximally

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Etiology Epidemiology

• Dysregulation of the intestinal immune system
• Environmental, infectious, autoimmune and genetic
  components
• Family history confers a 3 to 20 times greater
  chance
• Concordance in twins 6-10

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Etiology Epidemiology

• Prevalence 50-80/100,000
• Incidence 3-15/100,000
• Peak incidence between 15 and 30 years
• Second peak between 50 to 80 years
• Higher incidence in Jewish populations
• Non gender specific
• Negative correlation between smoking and
  ulcerative colitis

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History

• Severity of inflammation determines presentation
• With mild disease confined to rectum (ulcerative
  proctitis)
• insidious onset
• intermittent rectal bleeding
• mild diarrhea with or without mucus up to 4
  stools/day
• mild pain and tenesmus
• 1/3 of patients to 1/2 of patients

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History

• With moderate disease involving distal colon to
  splenic flexure
• frequent bloody stools
• mild anemia
• abdominal pain limited in severity
• low grade fever
• 1/3 of patients

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History

• With severe disease extending to cecum
  (pancolitis)
• frequent loose stools, 6/day
• severe cramping
• fever to 39.5ºC
• bleeding requiring transfusion
• poor nutritional state
• up to 1/3 of patients

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History

• With extremely severe disease
• decreased colonic motility causing decreased
  number of bowel movements
• severe bleeding
• toxic megacolon (fever, abdominal pain,
  dehydration, tachycardia)
• less than 10 of patients

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Physical Exam

• Physical exam
• can be normal
• abdominal tenderness
• pallor
• weight loss
• blood on DRE

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Extraintestinal manifestations

• uveitis/episcleritis
• erythema nodosum/pyoderma gangrenosum
• primary sclerosing cholangitis
• peripheral arthritis
• venous/arterial thromboembolism
• autoimmune hemolytic anemia
• apthous stomatitis

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Erythema nodosum
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Pyoderma gangrenosum
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Apthous stomatitis
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Differential Diagnosis

• Crohns disease
• Radiation colitis
• Ischemic colitis
• Infection (ie. Salmonella, Shigella,
  Campylobacter, E. coli, C. diff)
• Drugs including NSAIDs, retinoic acid, gold, OCPs
  (?)

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Labs

• Decreased hemoglobin, hematocrit
• Thrombocytosis
• Elevated ESR
• Hypoalbuminemia
• Elevated alk phos with PSC
• pANCA in 70 patients but not sensitive or
  specific
• Stool cultures to rule out other dx

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Diagnosis History, Physical, Endoscopy
Biopsy
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Flexible sigmoidoscopy

• mucosal ulceration, exudates, friability
• dilated mucosal vessels
• continuous colonic involvement
• pseudopolyps (reaction to prior inflammation in
  longstanding disease)
• colonoscopy and small bowel follow through
  required only with uncertain dx
• avoid colonoscopy or barium enema with extremely
  severe ulcerative colitis

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Pathology
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Pathology
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Biopsy

• crypt abscesses
• infiltration of plasma cells, neutrophils,
  lymphocytes, eosinophils
• atrophy of glands
• loss of mucin from goblet cells
• pseudopolyps

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Treatment options

• Mild disease
• oral and rectal 5-ASA compounds
• Moderate disease
• oral and topical 5-ASA compounds
• oral steroids
• azathioprine, 6-MP
• Severe disease
• IV steroids
• Cyclosporine
• Azathioprine, 6-MP, infliximab
• Colectomy

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Indications for proctocolectomy

• Uncontrolled hemorrhage
• Severe colitis failing aggressive medical
  management for two weeks
• Toxic megacolon
• Bowel perforation
• Unwanted side effects from prolonged steroids
• Dysplasia, strictures (30 risk of cancer with
  stricture formation)
• Debilitating disease refractory to medical
  treatment (FTT in children)
• Nonemergent

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Prognosis

• Proctitis/distal colitis
• 20 resolve spontaneously
• Majority in remission with medical therapy
• Proximal progression up to 15
• Severe disease
• Less likely to remit
• Worse with extremely young and extremely old
• Surgical intervention required in 30 after 20
  years

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Additional complications

• Risk of colorectal cancer in patients with
  recurring disease
• 5-10 after 20 years
• 12-20 after 30 years
• Patients with PSC especially at risk
• Colonoscopy recommended after 8-10 years disease
  duration with multiple biopsies
• Repeat every 1-2 years

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Take home points

• Ulcerative colitis presents with rectal bleeding
  in 20 or 60 year old
• Diagnose with flexible sigmoidoscopy
• Rule out Crohns/infectious process
• Only mucosal involvement
• Continuous from rectum extending proximally
• Treat with 5-ASA, steroids, immune modulation,
  proctocolectomy
• Recognize increased risk of colon cancer