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Updated: Dec 15 2021

Ulcerative Colitis

  • 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
    • 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
  • 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
  • Presentation
    • Symptoms
      • diarrhea
        • often with blood and mucus
        • recurrent episodes
      • fatigue
      • tenesmus
      • joint pain
      • abdominal pain
    • Physical exam
      • fever
      • rectal bleeding
      • pallor
  • 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
    • Diagnostic testing
      • diagnostic approach
        • diagnosis is based on clinical presentation (e.g., chronic diarrhea > 4 weeks) and is confirmed via endoscopic biopsy
      • 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
    • Anemia
    • Bleeding/hemorrhage
    • Perforation
    • Toxic megacolon
    • Colorectal cancer
      • patients should receive initial screening colonoscopy 8 years after pancolitis
    • Osteoporosis
    • Strictures
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