Ulcerative colitis

MOHAMED MUSTAFA
KHUH
INTERNAL MEDICINE
Contents

Soepel
Introduction
Etiology
Histology
pathophysiology
Sings and Symptoms
Diagnosise
Complications
Prognosis
Treatment
References
 Introduction

Ulcerative colitis:-
is an idiopathic chronic inflammatory disease of the colon that follows a course of relapse and
remission. In a small number of cases, ulcerative colitis is associated with extra-intestinal features.
Site of UC:-
1. Distal disease (left-sided colitis).
2. More extensive disease.
3. Some patients with pancolitis may have involvement of the terminal ileum due to an
incompetent ileocaecal valve.
Epidemiology:-
The incidence of uc is stable at 6-15\100000 annually, with a prevelance of 80-150\100000.
 Etiology

The aetiology is unknown. Ulcerative colitis is probably an autoimmune condition triggered by

colonic bacteria causing inflammation in the gastrointestinal tract.
A family history is present in around 25-40% of children; siblings of an individual with Crohn's
disease are 17-35 times more likely than the general population to develop the condition.
There is concern that non-steroidal anti-inflammatory drugs (NSAIDs) may increase the risk of
relapse or exacerbation of inflammatory bowel disease (IBD) - ulcerative colitis and Crohn's
disease - but the evidence is not strong.
The risk of IBD is increased in women using oral contraceptives but the absolute increase in risk is
very low.
The risk of ulcerative colitis is decreased in smokers.
histology

The severity of the disease may also be quite variable

histologically, ranging from minimal to florid ulceration and
dysplasia.
Carcinoma may develop. The typical histological
(microscopic) lesion of ulcerative colitis is the crypt abscess,
in which the epithelium of the crypt breaks down and the
lumen fills with polymorphonuclear cells.
The lamina propria is infiltrated with leukocytes. As the crypts
are destroyed, normal mucosal architecture is lost and
resultant scarring shortens and can narrow the colon.
pathophysiology
Signs and Symptoms

Diarrhea
rectal bleeding
tenesmus
passage of mucus
abdominal pain
other symptoms: anorexia, nausea, vomiting, fever,
weight loss
 Extra Intestinal Symptoms
 MILD MODERATE SEVERE
BOWEL MOVEMENTS
< 4 per day 4-6 per day >6 per day
BLOOD IN STOOL
small moderate Severe
FEVER
none <37,5C > 37,5C
TACHYCARDIA
none <90 mean >90 mean
pulse pulse
ANEMIA
mild >75% <75%
SEDIMENTATION
RATE
<30mm >30mm
 Clinical history
Physical examination
Laboratory tests
Colonoscopy
X-ray findings
Tissue biopsy (pathology)
 COLONOSCOPY : IBD
Diagnosis of IBD (UC vs. CD)
Allows visualization of large intestine
and ileum
Allows biopsies to examine colon tissue
Determines activity of disease
Important for pre-cancer surveillance
in UC and CD
COLONSCOPY : UC
Normal UC
Complications

Severe bleeding
Perforation
Severe dehydration
Liver disease (rare)
Kidney stones
Osteoporosis
Inflammation of skin, joints and eyes
An increased risk of colon cancer
toxic megacolon
Prognosis

Ulcerative colitis is a lifelong condition, with unpredictable relapses and

remissions.
Mortality is slightly higher than in the general population.
One study in Norway found that:-
The cumulative colectomy rate after ten years was 9.8%.
83% of people initially had relapsing disease but half were relapse-free after five
years.
About 20% of people with proctitis or left-sided colitis progressed to extensive colitis.
The prognosis for acute severe colitis depends on their initial response to
corticosteroid treatment.
Goals of Therapy for UC

Inducing remission
Maintaining remission
Restoring and maintaining nutrition
Maintaining patients quality of life
Surgical intervention (selection of optimal time for surgery)
Treatment
Medical treatment
Aminosalicylates (5-ASA)
Glucocorticoids
Azathioprine or 6-MP
Cyclosporine
Infliximab

Low roughage diet

No milk
Sometimes TPN
5-Aminosalicylic Acids
Sulfasalazine
Olsalazine
Balsalazide
Asacol
Rowasa Enema
Pentasa
Canasa Suppository
5-Aminosalicylic Acids

The mainstay treatment of mild to moderately active Ulcerative Colitis and

Crohn's Disease
5-ASA may act by
- Blocking the production of prostaglandins and leukotrienes

5-ASA absorbed in small intestine

- Do not reach colon
- Hence need delivery system
- 2 types of delivery systems
pH dependent resin or semi permeable membrane
5-ASA +bond (like sulfasalazine)
 No proven maintenance benefit in the treatment of either Ulcerative Colitis or Crohn's
Disease.
Budesonide:
less side effects,
its use is limited to patients with distal ileal and right-sided colonic disease
Immunosuppressive Agents

Methotrexate
Effective in steroid-dependent active Crohn's Disease and in
maintaining remission.
Potential side effects and risks include nausea, vomiting, infections,
bone marrow suppression, liver inflammation,.
Cyclosporine
Severe Ulcerative Colitis not responding to IV steroid &need urgent
proctocolectomy.
50% of the responders will need surgery within a year.
 Anti-TNF Therapy: Infliximab

Monoclonal antibody, binds soluble TNF.

Prompt onset, effects takes 6 weeks to max of 6m.
Indicated in fistulizing Crohns, refractory Crohn's Disease and refractory Ulcerative Colitis
Surgery in UC : why & when?
Intractability:
- Colitis refractory to medical management
- Often due to side effects of medical treatments
- Most common indication for operation

Dysplasia/Carcinoma:
- high-grade dysplasia : absolute indication

Massive Colonic Bleeding:

- very infrequent; less than 5% of urgent UC colectomies

Toxic Megacolon:
- acute colitis accompanied by significant colonic dilatation
- high fever, severe abdominal pain,tachycardia, leukocytosis
- predisposed to perforation
- treatment: IVF resuscitation, antibiotics, steroids, immunosuppressives
- clinical deterioration despite above : urgent operation
Ulcerative Colitis

Surgery (colectomy), is curative

Colectomy & ileostomy
Colectomy & ileo-anal Anastomosis (J-pouch)
Crohns Disease

Surgery does not cure

Disease recurs after a resection
Resection of inflamed segments to treat complications or
refractory disease