Ulcerative Colitis - Gastrointestinal

Snapshot
A 23-year-old female presents to the clinic for bloody diarrhea and abdominal pain for the past week. The pain is reported as intermittent, 7/10, and concentrated at the lower left quadrant (LLQ). She denies any rectal pain, trauma, or abnormal ingestions. She endorses subjective fever. A physical examination is unremarkable. A colonoscopy reveals friable rectal mucosa that bleeds easily on contact.
Introduction
Clinical definition chronic, autoimmune condition that results in the inflammation and ulceration of the colon and rectum characterized by recurring episodes of inflammation limited to the mucosal layer of the colon with treatment, the disease course typically consists of intermittent exacerbations alternating with long periods of complete symptomatic remission commonly involves the rectum and may extend proximally and continuously to involve other parts of the colon Epidemiology demographics more common in North American and Europe compared to other regions bimodal distribution in patients aged 15-30 years and > 60 years of age risk factors positive family history of inflammatory bowel disease (IBD) Ashkenazi Jewish descent smoking may lower risk Pathogenesis no direct cause has been identified but is likely due to genetic susceptibility with environmental triggers genetic susceptibility familial aggregation of the disease identification of multiple genetic loci linked to the disease environmental factors diets low in fiber and high in fat have been linked to the disease stress may exacerbate condition interactions of various factors ultimately lead to chronic, immune-mediated inflammation activated innate (e.g., macrophage) and acquired (e.g., T and B cell) immune responses associated with a Th2 cell response loss of tolerance to enteric commensal bacteria Associated conditions extraintestinal manifestations primary sclerosing cholangitis musculoskeletal involvement ankylosing spondylitis arthritis sacroiliitis eye involvement uveitis episcleritis cutaneous involvement erythema nodosum pyoderma gangrenosum venous and arterial thromboembolism autoimmune hemolytic anemia
Presentation
Symptoms diarrhea often with blood and mucus recurrent episodes fatigue tenesmus joint pain abdominal pain Physical exam fever rectal bleeding pallor
Studies
Diagnostic testing diagnostic approach diagnosis is based on clinical presentation (e.g., chronic diarrhea > 4 weeks) and is confirmed via endoscopic biopsy imaging abdominal radiograph not required for diagnosis but may be the best initial test for patients presenting with symptoms of colitis may see proximal constipation, mucosal thickening or “thumbprinting” secondary to edema, and colonic dilation barium enema may be normal in patients with mild disease positive findings include shortening of the colon, loss of haustra (“leadpipe appearance”), narrowing of the luminal caliber, and pseudopolyps computed tomography (CT) or magnetic resonance imaging (MRI) may demonstrate marked thickening of the bowel wall colonoscopy with biopsy biopsy is necessary to establish the diagnosis endoscopic findings may include touch friability, erosions, edema, and granularity of the mucosa non-neoplastic pseudopolyps inflammation of the rectum that extends proximally in a continuous and circumferential pattern biopsy features may include crypt abscess inflammatory cells (e.g., eosinophils) within the lamina propria studies stool studies for rule out of other causes of bloody diarrhea complete blood count, albumin, electrolytes, an markers of inflammation for evaluation of disease severity perinuclear antineutrophil cytoplasmic antibody (pANCA)
Differential
Crohn disease differentiating factors will often present with perianal disease with patchy inflammation on colonoscopy Infectious colitis differentiating factors will present with positive stool and tissue cultures/studies
Treatment
Management of the disease is dependent on the disease severity and extent of involvement First-line 5-aminosalicylic (5-ASA) drugs (e.g., sulfasalazine or mesalazine) enema is the best initial step corticosteroids (e.g., prednisone) used for acute attacks IV steroids for severe colitis iron supplementation used to management anemia secondary to gradual loss of blood Second-line immunosuppressive agents (e.g., azathioprine) and biological agents (e.g., infliximab or adalimumab) indicated in patients who cannot achieve remission with 5-ASA and corticosteroids Third-line total colectomy curative indicated in the event of exsanguinating hemorrhage, perforation, suspected carcinoma, severe colitis, toxic megacolon, or disease unresponsive to medical management
Prognosis, Prevention, and Complications
Anemia Bleeding/hemorrhage Perforation Toxic megacolon Colorectal cancer patients should receive initial screening colonoscopy 8 years after pancolitis Osteoporosis Strictures

Blood, Plasma, Serum	Reference Range
ALT	8-20 U/L
Amylase, serum	25-125 U/L
AST	8-20 U/L
Bilirubin, serum (adult) Total // Direct	0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca²⁺)	8.4-10.2 mg/dL
Cholesterol, serum	Rec: < 200 mg/dL
Cortisol, serum	0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h
Creatine kinase, serum	Male: 25-90 U/L Female: 10-70 U/L
Creatinine, serum	0.6-1.2 mg/dL
Electrolytes, serum
Sodium (Na⁺)	136-145 mEq/L
Chloride (Cl^-)	95-105 mEq/L
Potassium (K⁺)	3.5-5.0 mEq/L
Bicarbonate (HCO₃^-)	22-28 mEq/L
Magnesium (Mg²⁺)	1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)
24-28 wks // 32-36 wks	30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks	40-220 ng/mL // 80-350 ng/mL
Ferritin, serum	Male: 15-200 ng/mL Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma	Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250
pH	7.35-7.45
PCO₂	33-45 mmHg
PO₂	75-105 mmHg
Glucose, serum	Fasting: 70-110 mg/dL 2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation	Fasting: <5 ng/mL Provocative stimuli: > 7ng/mL
Immunoglobulins, serum
IgA	76-390 mg/dL
IgE	0-380 IU/mL
IgG	650-1500 mg/dL
IgM	40-345 mg/dL
Iron	50-170 μg/dL
Lactate dehydrogenase, serum	45-90 U/L
Luteinizing hormone, serum/plasma	Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL
Osmolality, serum	275-295 mOsmol/kd H₂O
Parathyroid hormone, serume, N-terminal	230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C)	20-70 U/L
Phosphorus (inorganic), serum	3.0-4.5 mg/dL
Prolactin, serum (hPRL)	< 20 ng/mL
Proteins, serum

Hematologic	Reference Range
Bleeding time	2-7 minutes
Erythrocyte count	Male: 4.3-5.9 million/mm³ Female: 3.5-5.5 million mm³
Erythrocyte sedimentation rate (Westergren)	Male: 0-15 mm/h Female: 0-20 mm/h
Hematocrit	Male: 41%-53% Female: 36%-46%
Hemoglobin A1c	≤ 6 %
Hemoglobin, blood	Male: 13.5-17.5 g/dL Female: 12.0-16.0 g/dL
Hemoglobin, plasma	1-4 mg/dL
Leukocyte count and differential
Leukocyte count	4,500-11,000/mm³
Segmented neutrophils	54%-62%
Bands	3%-5%
Eosinophils	1%-3%
Basophils	0%-0.75%
Lymphocytes	25%-33%
Monocytes	3%-7%
Mean corpuscular hemoglobin	25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration	31%-36% Hb/cell
Mean corpuscular volume	80-100 μm³
Partial thromboplastin time (activated)	25-40 seconds
Platelet count	150,000-400,000/mm³
Prothrombin time	11-15 seconds
Reticulocyte count	0.5%-1.5% of red cells
Thrombin time	< 2 seconds deviation from control
Volume
Plasma	Male: 25-43 mL/kg Female: 28-45 mL/kg
Red cell	Male: 20-36 mL/kg Female: 19-31 mL/kg

Cerebrospinal Fluid	Reference Range
Cell count	0-5/mm³
Chloride	118-132 mEq/L
Gamma globulin	3%-12% total proteins
Glucose	40-70 mg/dL
Pressure	70-180 mm H₂O
Proteins, total	< 40 mg/dL

Sweat	Reference Range
Chloride	0-35 mmol/L
Urine
Calcium	100-300 mg/24 h
Chloride	Varies with intake
Creatinine clearance	Male: 97-137 mL/min Female: 88-128 mL/min
Estriol, total (in pregnancy)
30 wks	6-18 mg/24 h
35 wks	9-28 mg/24 h
40 wks	13-42 mg/24 h
17-Hydroxycorticosteroids	Male: 3.0-10.0 mg/24 h Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total	Male: 8-20 mg/24 h Female: 6-15 mg/24 h
Osmolality	50-1400 mOsmol/kg H₂O
Oxalate	8-40 μg/mL
Potassium	Varies with diet
Proteins, total	< 150 mg/24 h
Sodium	Varies with diet
Uric acid	Varies with diet
Body Mass Index (BMI)	Adult: 19-25 kg/m²