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  • • Diffuse inflammatory disease confined to mucosa and submucosa

    • Crypts of Lieberkühn abscesses

    • Most commonly affects rectum

    • May spread to involve entire colon and distal ileum (backwash ileitis)

    • Diseased areas are contiguous

    • Increase in colorectal cancer risk

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Epidemiology

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  • • Bimodal age distribution

    • -15-30 years

      -60-80 years

    • Females affected slightly more than males

    • Incidence 5-12/100,000

    • Etiology unknown

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Symptoms and Signs

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  • • Rectal bleeding

    • Diarrhea

    • Tenesmus

    • Rectal urgency

    • Anal incontinence

    • Crampy abdominal pain

    • Fever

    • Vomiting

    • Weight loss

    • Dehydration

    • Extracolonic manifestations, including arthropathy, uveitis, iritis, pyoderma gangrenosum, and aphthous ulcers

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Laboratory Findings

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  • • Anemia

    • Leukocytosis

    • Elevated ESR

    • Hypoalbuminemia

    • Electrolyte depletion

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Imaging Findings

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  • Sigmoidoscopy

    • -Loss of normal vascular pattern

      -Friable

      -Hyperemic rectal mucosa

      -Mucosal granularity

      -Ulcers with bleeding and purulent exudates in advanced disease

    Barium enema

    • -Diffuse reticulated pattern

      -"Collar button" ulcers

      -Disappearance of haustral markings ("lead pipe")

      -Shortening of colon

    Abdominal x-ray

    • -Colonic dilation

      -Loss of haustral markings

    CT scan of abdomen

    • -May be helpful in puzzling cases

      -Colonic dilation

      -Loss of haustral markings

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  • • No radiographic, histologic, endoscopic findings pathognomonic

    • Infectious colitis

    • Mesenteric insufficiency

    • Neoplasm

    • Antibiotic-associated colitis

    • Chagas disease

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Rule Out

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  • • Infectious diarrhea (shigellosis, salmonellosis, E coli, amebiasis)

    • Crohn disease

    • Malignancy

    • Diverticular disease

    Clostridium difficile colitis

    • Toxic megacolon

    • Infectious colitis and pseudomembranous colitis

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  • • Flexible sigmoidoscopy and colonoscopy

    • Contrast enema

    • CBC

    • Metabolic panel

    • Liver function panel

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When to Admit

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  • • Dehydration or malnutrition

    • Severe rectal bleeding

    • Abdominal pain

    • Bowel obstruction

    • Intractable diarrhea

    • Severe, acute, or fulminant attack

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When to Refer

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  • • Unclear diagnosis

    • Impending perforation

    • Suspicion of toxic megacolon

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  • • Initially, medical unless complications arise

    • Surgery potentially curative

    • Treatment focus on containing and reducing inflammation

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Surgery

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  • • Total colectomy, rectal mucosectomy, and ileoanal anastomosis

    • Proctocolectomy with ileostomy or continent ileal pouch

    • Subtotal colectomy with ileorectal anastomosis

    • Emergent procedures should be tailored to fit the extent of the illness; typically total abdominal colectomy and ileostomy

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Indications

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  • • Emergency surgery for perforation

    • Urgent surgery for

    • -Medically refractory toxic megacolon

      -Massive hemorrhage

      -Fulminant acute flare unresponsive to medication

      -Acute obstruction

      -Suspicion or demonstration of colorectal cancer

    • Medically refractory chronic disease resulting in malnutrition, complications from medical management, or inability to work or perform activities of daily living

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Medications

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  • • Sulfasalazine

    • Corticosteroids

    • Mesalamine

    • Cyclosporine for steroid-resistant colitis

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Treatment Monitoring

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  • • Endoscopy

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