1. Ulcerative colitis (UC)
Domina Petric, MD

2. 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).

3. 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.

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

5. Medscape.com
Wikipedia.org

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

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

8. Systemic symptoms in attacks are:
fever
malaise
anorexia
weight loss

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

10. 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

11. Extraintestinal signs
primary sclerosing cholangitis
cholangiocarcinoma
nutritional deficits
amyloidosis

12. 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.

13. 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.

14. Radiopaedia.com

15. 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
g/L
<105 g/L
ESR
<30
>30
CRP
<16
>45

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

17. 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.

18. 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.

19. 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.

20. 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).

21. 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.

22. 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.

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

24. 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

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

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