Ulcerative Colitis

Snapshot

• A 17-year-old female presents to the emergency department with complaints of subjective fever and crampy abdominal pain for the past week. Today, she had an episode of bloody bowel movement, which has never happened before. A physical examination demonstrates mild conjunctival pallor but is otherwise unremarkable. ESR and CRP are elevated.  

Introduction

• Clinical definition
  • chronic, autoimmune condition that results in the inflammation and ulceration of the colon and rectum
    • characterized by recurring episodes of inflammation limited to the mucosal layer of the colon 
    • with treatment, the disease course typically consists of intermittent exacerbations alternating with long periods of complete symptomatic remission
  • commonly involves the rectum and may extend proximally and continuously to involve other parts of the colon 
• Epidemiology
  • demographics
    • more common in North American and Europe compared to other regions
    • bimodal distribution in patients aged 15-30 years and > 60 years of age
  • risk factors
    • positive family history of inflammatory bowel disease (IBD)
    • Ashkenazi Jewish descent
    • smoking may lower risk
• Pathogenesis
  • no direct cause has been identified but is likely due to genetic susceptibility with environmental triggers
    • genetic susceptibility
      • familial aggregation of the disease
      • identification of multiple genetic loci linked to the disease
    • environmental factors
      • diets low in fiber and high in fat have been linked to the disease
      • stress may exacerbate condition
• Associated conditions 
  • extraintestinal manifestations
    • primary sclerosing cholangitis
    • musculoskeletal involvement
      • ankylosing spondylitis
      • sacroiliitis
    • eye involvement
      • uveitis 
      • episcleritis 
    • cutaneous involvement
      • erythema nodosum
      • pyoderma gangrenosum 
    • venous and arterial thromboembolism
• autoimmune hemolytic anemia

Presentation

• Symptoms 
  • diarrhea  
    • often with blood and mucus
    • recurrent episodes
  • fatigue
  • tenesmus
  • joint pain
  • abdominal pain
• Physical exam
  • fever
  • rectal bleeding
• pallor

Imaging

• Abdominal radiograph 
  • not required for diagnosis but may be the best initial test for patients presenting with symptoms of colitis
  • may see proximal constipation, mucosal thickening or “thumbprinting” secondary to edema, and colonic dilation
• Barium enema 
  • may be normal in patients with mild disease
  • positive findings include shortening of the colon, loss of haustra (“leadpipe appearance”), narrowing of the luminal caliber, and pseudopolyps 
• Computed tomography (CT) or magnetic resonance imaging (MRI)
  • may demonstrate marked thickening of the bowel wall
• Colonoscopy with biopsy
  • biopsy is necessary to establish the diagnosis
  • endoscopic findings may include 
    • touch friability, erosions, edema, and granularity of the mucosa
    • non-neoplastic pseudopolyps 
    • inflammation of the rectum that extends proximally in a continuous and circumferential pattern
  • biopsy features may include 
    • crypt abscess
• inflammatory cells (e.g., eosinophils) within the lamina propria

Studies 

• Stool studies
  • to rule out other causes of bloody diarrhea
• Complete blood count, albumin, electrolytes, an markers of inflammation (e.g., ESR)
  • for evaluation of disease severity
• Perinuclear antineutrophil cytoplasmic antibody (pANCA) 

Differential

• Crohn disease 
  • differentiating factors 
    • will often present with perianal disease with patchy inflammation on colonoscopy  
• Infectious colitis 
  • differentiating factors
• will present with positive stool and tissue cultures/studies

Treatment

• Management of the disease is dependent on the disease severity and extent of involvement
• First-line
  • 5-aminosalicylic (5-ASA) drugs (e.g., sulfasalazine or mesalazine)
    • enema is the best initial step 
  • corticosteroids (e.g., prednisone) 
    • used for acute attacks
    • IV steroids for severe colitis 
  • iron supplementation
    • used to management anemia secondary to gradual loss of blood
• Second-line
  • immunosuppressive agents (e.g., azathioprine) and biological agents (e.g., infliximab or adalimumab)
    • indicated in patients who cannot achieve remission with 5-ASA and corticosteroids
• Third-line
  • total colectomy
    • curative
• indicated in the event of exsanguinating hemorrhage, perforation, suspected carcinoma, severe colitis, toxic megacolon, or disease unresponsive to medical management

Complications

• Anemia
• Bleeding/hemorrhage
• Perforation
• Toxic megacolon 
• Colorectal cancer
  • patients should receive initial screening colonoscopy 8 years after pancolitis
• Osteoporosis
• Strictures