Ulcerative colitis (UC) Domina Petric, MD

Introduction UC is a relapsing and remitting inflammatory disorder of the colonic mucosa. It may affect just the rectum (proctitis, 50%) or extend to involve part of the colon (left-sided colitis, 30%). It can involve the entire colon (pancolitis, 20%). UC almost never spreads proximal to the ileocaecal valve, except in the case of BACKWASH ILEITIS (rare).

Pathology Hyperaemic/haemorrhagic granular colonic mucosa with or without pseudopolyps formed by inflammation. Punctate ulcers may extend deep into the lamina propria. Inflammation is normally not transmural.

Histology inflammatory infiltrate goblet cell depletion glandular distortion mucosal ulcers crypt abscesses

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Epidemiology Prevalence is 100-200/100000. Incidence is 10-20/100000/year. Most present aged 15-30 years. It is more prevalent in nonsmokers. Symptoms may relapse on stopping smoking.

Symptoms Episodic or chronic diarrhoea: blood, mucus. Crampy abdominal discomfort. Bowel frequency relates to severity. Urgency/tenesmus, especially in rectal disease.

Systemic symptoms in attacks are: fever malaise anorexia weight loss

Signs There may be no signs. In acute, severe UC there may be fever, tachycardia and a tender, distended abdomen.

Extraintestinal signs Clubbing (Wikipedia.org) Extraintestinal signs clubbing aphthous oral ulcers erythema nodosum pyoderma gangrenosum conjunctivitis episcleritis iritis large joint arthritis sacroiliitis ankylosing spondylitis fatty liver

Extraintestinal signs primary sclerosing cholangitis cholangiocarcinoma nutritional deficits amyloidosis

Tests Blood: full blood count, erythrocyte sedimentation rate (ESR), CRP, urea, creatinine, electrolytes, blood culture, liver function tests. Stool microbiology to exclude Campylobacter, C. difficile, Salmonella, Shigella, E. coli, amoebae.

Tests Abdominal X ray: no faecal shadows, mucosal thickening or islands. Erect chest X ray: if perforation. Barium enema: contraindicated during severe attacks. Colonoscopy: best choice, biopsy.

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Truelove, Witts criteria Variable Mild UC Moderate UC Severe UC Motions/day <4 4-6 >6 Rectal bleeding Small Moderate Large T0C at 6 AM Apyrexial 37,1-37,80 C >37,80 C Resting pulse <70 bpm 70-90 bpm >90 bpm Haemoglobin >110 g/L 105-110 g/L <105 g/L ESR <30 >30 CRP <16 >45

Complications perforation bleeding toxic dilatation of colon (mucosal islands, colonic diameter >6 cm) venous thrombosis colonic cancer

Complications Intra-epithelial neoplasms may occur in flat, normal-looking mucosa. Surveillance colonoscopy is done every 2-4 years with 4 random biopsies/10 cm of mucosa. Endomicroscopy may increase detection rates.

Therapy for mild UC 5-ASA (sulfasalazine, mesalazine). Steroids: prednisolone 20 mg/d per os may be useful for inducing remission. If the patient is improving, lower steroids slowly.

Therapy for moderate UC Oral prednisolone 40 mg/d for 1 week, then 30 mg/d for 1 week, than 20 mg/d for 4 more weeks and 5-ASA and twice-daily steroid enemas. If the patient is improving, lower steroids gradually.

Severe UC Admit in hospital. Nil by mouth. Iv. hydration: 1 L of 0,9% saline + 2 L of dextrose-saline/24 hours + 20 mmol K+/L (less if elderly).

Severe UC Hydrocortisone 100 mg/6 hours iv. Rectal steroids, hydrocortisone 100 mg in 100 mL 0,9% saline/12 hours per rectum. Monitor temperature, pulse and blood pressure. Record stool frequency and character.

Severe UC Daily blood tests. Parenteral nutrition is required if the patient is severely malnourished. After improvement, transfer to prednisolone per os 40 mg/24 h with 5-ASA to maintain remission.

Severe UC If there is no improvement: CICLOSPORIN or INFLIXIMAB. Urgent colectomy in refractory patients with very severe disease.

Indications for surgery Indications for proctocolectomy and terminal ileostomy or colectomy with ileo-anal pouch later are: perforation massive haemorrhage toxic dilatation failed medical therapy

Immunomodulation Indications for azathioprine, methotrexate, infliximab, adalimumab, ciclosporin or tacrolimus: no remission with steroids prolonged use of steroids required

Literature Oxford Handbook of Clinical Medicine. Longmore M. Wilkinson I. B. Baldwin A. Elizabeth W. Ninth edition. Wikipedia.org Medscape.com Radiopaedia.com