Ulcerative Colitis

Inflammation limited to mucosal layer of the digestive tract

Starts in the rectum and extends proximally in continuous fashion
Classification
Ulcerative proctitis
o rectum
Ulcerative proctosigmoiditis 40-50% rectum and sigmoid
o Rectum and sigmoid
Left-sided aka distal 30-40% past sigmoid
o As far as splenic flexure
Extensive
o Past splenic flexure but sparing cecum
Pancolitis 20%
o Involves cecum
10-20% have terminal ileum involvement
o Who gets it?
Peak incidence at around 20 years old second peak at ~50
Never or non-smokers; <10% smoke
Higher incidence in higher latitudes
Appendectomy seems to be protective against the development of UC
o Presentation and disease course
These pts have recurring episodes of inflammation diarrhea is bloody ranges from hematochezia to blood mixed
with stool depending on location so things like strictures and fistulas are less likely to occur tenesmus,
small/frequent bowel movements, and incontinence are more likely to occur
The onset of symptoms is usually gradual in these patients and tend to develop over several weeks to months.
Like Crohns they may have non-specific systemic symptoms such as fever, fatigue, and anemia which is usually Fe def anemia dt
the blood loss, but they can also have anemia of chronic disease, as well as auto-immune hemolytic anemia
Limited to rectum or sigmoid: 30-50%
Left sided: 20-30%
Pancolitis: 20%
o Complications and extra intestinal manifestations
Stricture (usually malignant)
Dysplasia or colorectal cancer
Sclerosing cholangitis
Cholangiocarcinoma (1/2 of all bile duct cancers are associated with UC)
Toxic megacolon more common in UC one of the leading COD in these patients
Psychosocial issues such as depression can also be common
Once again arthritis is the MC EIM
Primarily involves large joints and is
Also have a higher incidence of Ankylosis spondylitis
Eye
Most frequent eye diseases are uveitis and episcleritis
Scleritis, iritis, conjuctivitis have also been associated
Skin
MC erythema nodosum and pyoderma grangrenosum
Hepatobiliary
Primary sclerosing cholangitis, fatty liver, and auto-immune liver disease
Hematology
Increased risk for both venous and arterial thromboembolism
o In 1 study
About double the risk in hospitalized patients
About 14 times the risk in ambulatory patients
Pulmonary
Rare
o Airway inflammation, parenchymal lung disease, serositis, thromboembolic disease as I just mentioned
o Evaluation
The diagnosis of ulcerative colitis is suggested by the symptoms of abdominal pain, rectal bleeding, and diarrhea. As
there is no gold standard for diagnosis, the ultimate diagnosis relies on a combination of symptoms, the appearance of
the colonic lining at the time of endoscopy, histologic features of biopsies of the colonic lining, and studies of stool to
exclude the presence of infectious agents that may be causing the inflammation.
3 goals: rule out other diagnosis, establish the diagnosis of UC, determine the severity of the disease
Extension may occur over time; colonoscopy is needed for determination
Severity
Mild
o Patients with mild clinical disease have four or fewer stools per day with or without blood, no signs of systemic
toxicity, and a normal erythrocyte sedimentation rate (ESR). Mild crampy pain, tenesmus, and periods of
constipation are also common, but severe abdominal pain, profuse bleeding, fever, and weight loss are not part of
the spectrum of mild disease.
Moderate
o Patients with moderate clinical disease have frequent loose, bloody stools (>4 per day), mild anemia not requiring
blood transfusions, and abdominal pain that is not severe. Patients have minimal signs of systemic toxicity,
including a low-grade fever. Adequate nutrition is usually maintained and weight loss is not associated with
moderate clinical disease.
Severe
o Patients with a severe clinical presentation typically have frequent loose bloody stools (6 per day) with severe
cramps and evidence of systemic toxicity as demonstrated by a fever (temperature 37.5C), tachycardia (HR
90 beats/minute), anemia (hemoglobin <10.5g/dL), or an elevated ESR (30 mm/hour). Patients may have rapid
weight loss.
Mayo Calculator
History
Used to rule out other diagnosis
o Recent travel and abx use, STD, abdominal/pelvic radiation, excessive NSAID use, athersclerotic disease
o For the immunocompromised CMV may mimic UC
PE
Usually benign physical exam especially in those patients with mild disease
Possible findings include: Abdominal tenderness, Rectal exam may show blood
Patients with prolonged diarrhea may present with hypotension and tachycardia, fever, and pallor. Loss of
subcutaneous fat, muscle wasting, and peripheral edema dt wt loss and malnutrition
Labs
Stool studies
o Stool studies should include stool Clostridium difficile toxin, routine stool cultures (Salmonella, Shigella,
Campylobacter, Yersinia), and specific testing for E. coli O157:H7. Microscopy for ova and parasites (three
samples) and a Giardia stool antigen test should also be performed, particularly if the patient has risk factors such
as recent travel to endemic areas.
Serologic studies
o Auto-Antibodies: NOT PART of WORKUP
pANCA

CBC, electrolytes, and albumin
o Anemia
o ESR >30
o Low albumin
o Electrolyte abnormalities secondary to diarrhea
Consider STD testing for patients with severe rectal symptoms such as tenesmus
o Neisseria, HSV, syphillis
Patients with suspected primary scleroging cholangitis
o Alkaline phosphatase
Colonoscopy and biopsy
Findings are nonspecific but necessary to establish the chronicity and severity of the inflammation as well as to rule out
other causes of colitis
Inflammation usually involves the rectum and extends proximally circumferentially.
Suggestive findings on colonoscopy: loss of vascular markings dt engorgment of mucosa giving erythematous
appearance, granularity of the mucosa, petechiae, exudates, edema, erosions, touch friability, may have spontaneous
bleeding severe cases may have pseudopolyps
As far as biopsy you will find: crypt abscesses, crypt branching, crypt atrophy. May see epithelial abnormalities like
mucin depletion and paneth cell metaplasia increased lamina propria cellularity and eosinophils
Avoid in hospitalized patients with severe colitis bc of the potential to precipitate toxic megacolon use flexible
sigmoidoscopy and limit evaluation to rectum and distal sigmoid colon
o Management