Colitis, Ulcerative

• • 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

Epidemiology

• • Bimodal age distribution

  • -15-30 years

    -60-80 years

  • Females affected slightly more than males

  • Incidence 5-12/100,000

  • Etiology unknown

Symptoms and Signs

• • 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

Laboratory Findings

• • Anemia

  • Leukocytosis

  • Elevated ESR

  • Hypoalbuminemia

  • Electrolyte depletion

Imaging Findings

• • 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

• • No radiographic, histologic, endoscopic findings pathognomonic

  • Infectious colitis

  • Mesenteric insufficiency

  • Neoplasm

  • Antibiotic-associated colitis

  • Chagas disease

Rule Out

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

  • Crohn disease

  • Malignancy

  • Diverticular disease

  • Clostridium difficile colitis

  • Toxic megacolon

  • Infectious colitis and pseudomembranous colitis

• • Flexible sigmoidoscopy and colonoscopy

  • Contrast enema

  • CBC

  • Metabolic panel

  • Liver function panel

When to Admit

• • Dehydration or malnutrition

  • Severe rectal bleeding

  • Abdominal pain

  • Bowel obstruction

  • Intractable diarrhea

  • Severe, acute, or fulminant attack

When to Refer

• • Unclear diagnosis

  • Impending perforation

  • Suspicion of toxic megacolon

• • Initially, medical unless complications arise

  • Surgery potentially curative

  • Treatment focus on containing and reducing inflammation

Surgery

• • 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

Indications

• • 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

Medications

• • Sulfasalazine

  • Corticosteroids

  • Mesalamine

  • Cyclosporine for steroid-resistant colitis