BACKGROUND

Figure 1: Major Type of IBD (Kumar, et al., 2007)

BACKGROUND

Ulcerative Colitis:

was first described in the mid-1800s incidence is 1.2-20.3 per 100.000 person/year >> than CD most common form of IBD in adults linked to smoking, diets high in fat and sugar, medication, stress, and high socioeconomic status incidence is in Europe and America and lowest in Asia frequency in developed countries has been increasing

Only few articles discuss about UC

OBJECTIVE

To review the current understanding of the pathophysiology, diagnosis, and treatment of ulcerative colitis to date

PATHOGENESIS

Genetic factors Microbiologic factors

Mucosal immune

response

Epithelial dysfunction and autoimmunity

CLINICAL FEATURES

Mucosal inflammation, commencing in the rectum (proctitis) and spreading proximally to the colon

Bloody diarrhea with or without mucus Gradual onset, often followed by periods of spontaneous remission and subsequent relapses (chronicexacerbation-remission)

Fecal urgency, tenesmus, constipation, abdominal pain,

fever, malaise, weight loss may occur

EXTRAINTESTINAL MANIFESTATION

COMPLICATION

DIAGNOSTIC

Endoscopic*

radiologic

Biopsy*

ultrasonographic

ENDOSCOPIC

Colonoscopy

Uniformly inflamed mucosa that starts at the anorectal verge and extends proximally with an abrupt or a gradual transition from affected to normal mucosa

ENDOSCOPIC

Mild Ulcerative Colitis (UC)

Mucosa has a granular

Erythematous appearance
Friability Loss of the vascular pattern

Moderate UC :Erosions or microulcerations

Severe UC : shallow ulcerations with spontaneous bleeding Differentiate UC from CD : Rectal sparing, aphthous ulcers, skip lesions, a cobblestone pattern, longitudinal and irregular ulcers

HISTOLOGIC EVALUATION

Inflammation restricted to the mucosal layer

Infiltrates consist primarily of lymphocytes, plasma cells,

granulocytes

Goblet cell depletion Distorted crypt architecture Epitheloid granuloma are not present : typical of CD Epithelial dysplasia No exact criteria for diagnosis of UC : but the presence of 2 or 3 histologic feature above will suffice

LABORATORY TEST

Helpful in assessing and monitoring disease activity and

differentiating UC from other form of colitis

CBC Fecal lactoferrin or calprotectin ->severity Stool cultures for Clostridium difficile, campylobacter species, Escherichia coli

Histologic, immunochemical, serologic, culture, DNA testing -> rule out CMV infection

ASCA and pANCA (differentiate UC, CD, IC)

MEDICAL THERAPY

Level of clinical activity

Mild, moderate, or severe

Extent of disease

Proctitis, left-sided disease, extensive disease, or pancolitis

Course of disease during FU

Patients preferences

PROCTITIS

Mild to moderate: given for 2 weeks and can be repeated :

Mesalamine supp 1 g/d or enema 2-4 g/d

If fails : hydrocortisone 100mg/d are a next step

No response to rectally : oral glucocorticoids

(Prednisone up to 40 mg/d)

LEFT SIDED COLITIS TO EXTENSIVE UC

Combination of oral and rectal 5-aminosalicylate up to 4,8 g/d A once daily dose of 5-aminosalycilate :2 g/d

Oral glucocorticoid or immunosuppressive agents (azathioprine or 6-mercaptopurine) I.V glucocorticoid : 5-7 days Monoclonal antibody against TNF-alfa: infliximab

5mg/kg of body weight at 0,2, and 6 weeks

MAINTENANCE OF REMMISION

Oral and rectal 5-aminosalicylate

Azathioprine 2,5mg/kg body weight 6-mercaptopurine 1,5 mg/kg body weight

Anti TNF-alfa : infliximab Respond to probiotic therapy : VSL#3

SURGICAL TREATMENT

Reported Colectomy : <5% - >20% patients with UC Surgery can be curative Indication for surgery :

Failure of medical therapy Intractable fulminant colitis Toxic megacolon

Perforation
Uncontrollable bleeding Intolerable side effects of medications Stricture

Uresectable high grade or multifocal dysplasia

Dysplasia-associated lession or masses Cancer Growth retardation in children

SURGICAL TREATMENT
Possible complication of surgery:

Small-bowel obstruction
Fistulas Persistent pain Sexual and bladder dysfunction infertility

Total proctolectomy with ileal pouch-anal anastomosis (IPAA) *

Complication : pouchitis (40%)

Symptoms : increased stool frequency, urgency, incontinence, seepage, abdominal and perianal discomfort

FUTURE IMPLICATIONS

Figure 2. Agents for Which Evidence of Therapeutic Eff icacy in Ulcerative Colitis is Established or Preliminary

THANK YOU