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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

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(M2.GI.16.5) A 42-year-old male with a history of ulcerative colitis presents to the emergency room with four-day history of nausea, bloody diarrhea, and abdominal pain. He is on medical management with 5-aminosalicylic acid (5 ASA). Examination shows an ill appearing man with a tense, tympanitic abdominal exam. He is unable to be fully examined due to the abdominal pain. Vitals are T 38.2 C, HR 102 bpm BP 133/92 mmHg,2 RR 20 bpm, and O2 Sat 100% on room air. In the ED an abdominal radiograph is shown in Figure A. Which of the following is the diagnosis?

QID: 102759
FIGURES:
1

Sigmoid volvulus

0%

(0/8)

2

Perforated diverticulitis

0%

(0/8)

3

Toxic megacolon

100%

(8/8)

4

Small bowel obstruction

0%

(0/8)

5

Cecal volvulus

0%

(0/8)

M 6 D

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(M3.GI.16.7) A 53 year-old woman with history of ulcerative colitis presents to the emergency department with a severe flare. The patient reports numerous bloody loose stools, and has been febrile for two days. Vital signs are: T 101.9 HR 98 BP 121/86 RR 17 Sat 100%. Abdominal exam is notable for markedly distended abdomen with tympani and tenderness to palpation without guarding or rebound. KUB is shown in figure A. CT scan shows markedly dilated descending and sigmoid colon with no perforations. What is the next best step in management for this patient?

QID: 102761
FIGURES:
1

Oral prednisone

0%

(0/0)

2

IV hydrocortisone

0%

(0/0)

3

Rectal 5-ASA

0%

(0/0)

4

IV Metoclopramide

0%

(0/0)

5

IV Ondansetron

0%

(0/0)

M 11 D

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Evidence (4)
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