Ulcerative Colitis Overview

Epidemiology: Prevalence of ~1:1000, with onset usually in 20s.  10% of cases are familial

 

Pathology: Involves the rectum >95% of the time, and extends proximally and contiguously.  On histology, there are superficial microulcerations, as opposed to Crohn’s disease which has transmural inflammation and noncaseating granulomas.

 

Clinical Presentation:

• Typically presents with grossly bloody diarrhea, lower abdominal cramps, and urgency.  Rectal pain is unusual.  Often have a gradual onset of symptoms, with intermittent exacerbations with periods of remission in between.    Contrast with Crohn’s disease, which usually presents with mucus-containing diarrhea that is usually not grossly bloody, with prominent constitutional symptoms of fever, malaise, weight loss, and abdominal pain; strictures, fistulas, and abscesses are also seen.
• In UC, the feared complications include fulminant colitis which progresses rapidly over 1-2 weeks, with fever, hypotension, and multiple BM’s day.  ~20% of patients with fulminant colitis progress to Toxic Megacolon, which you should suspect when colonic dilation exceeds 6 cm – this is an emergency due to risk of perforation as well as severe systemic toxicity. 

 

Differential Diagnosis of Ulcerative Colitis:

• Infectious Colitis – most important to rule this out; also, many of these infectious can co-exist and complicate UC!   C.diff, CMV, Entamoeba histolytica, Salmonella, Shigella, E.coli O157:H7. Also, STDs can cause proctitis (e.g. gonorrhea)
• Radiation Colitis
• Ischemic Colitis
• Drug side effect – hemorrhagic colitis is a rare side effect of some drugs, such as PCN and fluoroquinolones.

 

Extraintestinal Manifestations of IBD:

1) Skin – Erythema Nodosum, Pyoderma Gangrenosum
2) Arthritis – seronegative spondyloarthropathies including ankylosing spondylitis
3) Aphthous ulcers
4) Eye – Iritis, Episcleritis, Uveitis
5) Primary Sclerosing Cholangitis (UC > Crohn’s)
6) Autoimmune Hemolytic Anemia
7) Lung disease including bronchiecstasis

 

Serologies:

• UC patients are P-ANCA in 60-70% - associated with pancolitis and primary sclerosing cholangitis
• Crohn’s disease patients have positive ASCA serologies (Anti-Saccharomyces Cerevisiae Antibodies) in 60-70%.  
• Diagnosis should never be made based on serologies alone – they are an adjunct for diagnosis, in addition to clinical presentation, imaging, and most importantly endoscopic findings (macro and microscropically).

 

Treatment of Acute Flares:

A. Mild Flares-     5-ASA compounds are the mainstay.  Have anti-inflammatory and immunosuppressive effects (the exact mechanism is unknown).   Different formulations differ in which part of the intestine they are most active. Can be given orally or rectally as suppositories.

• Mesalamine – formulations include Asacol (work in terminal ileum, colon), Pentasa (small intensine and colon)
• Sulfasalazine – acts more in the colon
• Budesonide – oral steroid with less systemic absorption.

B. Moderate Flares - typically treated with oral steroids (i.e. Prednisone).

C. Severe Flares

• IV Steroids (Solumedrol) – mainstay of treatment for acute, severe flares
• Cyclosporine – increasing evidence for efficacy.
• Infliximab – more data for Crohn’s Disease, but increasingly being studied for UC as well (but so far appears less efficacious than Cyclosporin
• , but not compared head-to-head as of yet)
• In addition to the above, bowel rest and IVFs are standard part of supportive therapy.

Maintenance therapy for IBD involves 5-ASA compounds (1st-line), then  Azathioprine/6-MP and Methotrexate.   Infliximab, as mentioned above, is usually used for severe Crohn’s disease, especially with fistulizing disease.

 

 

UC and pregnancy:

-no clear association of pregnancy and IBD flares (1/3 improve during pregnancy, 1/3 worsen and 1/3 stay the same)

-pregnancy outcomes: increased risk of LBW infants, small for gestational age and preterm delivery; prognosis is worse if disease is not controlled at conception

-drug therapy must be tailored (infliximab is pregnancy class B, steroids, cyclosporine are class C, Azathiporine and 6-MP are class D)

 

 

Role of surgery:
1) UC - Colectomy should be considered for severe disease refractory to medical therapy, or for anyone with fulminant colitis or toxic megacolon that does not quickly respond to treatment.  Colectomy is curative.
2) Crohn’s Disease – surgery plays a less prominent role and is reserved for strictures, fistulas, and abscesses.  Problem is that these problems tend to recur even after surgery.

 

 

(Victoria Kelly MD, 7/22/10)

(Chanu Rhee MD, 2/18/11)