Large Intestine: Ulcerative Colitis (UC)

Ulcerative Colitis (UC)

Basics

  • Inflammatory Bowel Disease (IBD) – Chronic Inflammatory Disease of the Colonic Mucosal Layer
  • Associated with HLA B27
    • Also Ankylosing Spondylitis & Sacroiliitis
  • Smoking is Not a Risk Factor & May Actually Be Protective
  • Increased Risk of Malignancy Starting 8-10 Years After Disease Onset
  • Surgery is Curative

Inflammation

  • Continuous Inflammation from the Rectum Proximally
  • Spares the Anus
  • Inflammation Confined to the Mucosa/Submucosa
  • Most Common Site of Perforation: Transverse Colon

Presentation

  • Symptoms:
    • Diarrhea – Most Common Symptom
    • Bloody Stools
    • Abdominal Pain
    • Tenesmus (Feeling of a Frequent Need to Defecate Even if Already Passed a Bowel Movement)
    • Fecal Incontinence
  • Complications:
    • GI Bleed
    • Stricture
    • Backwash Ileitis
    • Toxic Colitis
    • Toxic Megacolon
    • Perforation
  • Fulminant Ulcerative Colitis
    • Definition: ≥ 10 Bloody Stools Daily, Often with Pain & Distention
    • A Subset of Severe Ulcerative Colitis

 Extraintestinal Manifestations

  • Arthritis – Most Common Extraintestinal Manifestation
  • Ankylosing Spondylitis
  • Uveitis or Episcleritis
  • Rash – Erythema Nodosum or Pyoderma Gangrenosum
  • Primary Sclerosing Cholangitis
  • Venous Thromboembolism

Diagnosis

  • Dx: Based on Presence of Chronic Diarrhea ≥ 4 Weeks & Evidence of Chronic Colitis oin Endoscopy
    • Must Exclude Other Similar Causes
  • Testing:
    • Imaging (CT or MRI)
      • “Lead Pipe” Appearance of the Colon on Abdominal XR
      • “Collar Button Ulcers” from Undermining at the Lateral Ulcer Edges
    • Colonoscopy with Intubation of Terminal Ileum & Mucosal Bx
  • Morphology:
    • Mucosal Edema (Earliest Sign)
    • Friable Mucosa – Causes Bleeding
    • Polymorphonuclear Cells in Lamina Propria
    • Crypt Abscess
    • Mucosal Ulceration
  • Pseudopolyps of Surrounding Mucosa

Montreal Classification

  • Extent
    • E1: Ulcerative Proctitis: Confined to Rectum
    • E2: Left-Sided/Distal Ulcerative Colitis: Distal to Splenic Flexure
    • E3: Extensive Ulcerative Colitis/Pancolitis: Extends Proximal to the Splenic Flexure
  • Severity
    • S0: Clinical Remission: Asymptomatic
    • S1: Mild: ≤ 4 Stools Daily with No Systemic Illness & Normal ESR
    • S2: Moderate: > 4 Stools Daily with Minimal Signs of Toxicity
    • S3: Severe: ≥ 6 Bloody Stools Daily & ≥ 1 Sign of Systemic Toxicity
      • Signs: Pulse Rate ≥ 90, Temperature ≥ 37.5 C, Hgb < 10.5 g/dL or ESR ≥ 30 mm/h

Mayo Scoring System

  • Scores 0-12 Indicate Disease Severity & Should Be Used to Compare to Previous Patient Scores
  • Stool Pattern:
    • 0: Normal Number of Stools
    • 1: 1-2 More Stools Than Normal
    • 2: 3-4 More Stools Than Normal
    • 3: ≥ 5 More Stools Than Normal
  • Most Severe Rectal Bleeding of the Day:
    • 0: None
    • 1: Bloody Streaks ≤ Half the Time
    • 2: Blood in Most Stools
    • 3: Pure Blood Passed
  • Endoscopic Findings:
    • 0: Inactive: Normal
    • 1: Mild: Erythema, Decreased Vascular Pattern or Mild Friability
    • 2: Moderate: Marked Erythema, Absent Vascular Pattern, Friability or Erosions
    • 3: Severe: Spontaneous Bleeding or Ulceration
  • Global Physician Assessment:
    • 0: Normal
    • 1: Mild Colitis
    • 2: Moderate Colitis
    • 3: Severe Colitis

Skip Lesions of Crohn’s (Left) Compared to Continuous Lesion of UC (Right) 1

“Lead Pipe” Sigmoid Colon on XR 1

Crypt Abscess 3

Pseudopolyps 4

Ulcerative Colitis (UC) – Treatment

Medical Treatment

  • Acute Flares/Fulminant Colitis: Steroids and/or Biologics
    • Biologics:
      • Infliximab (Remicade) – TNF-α Inhibitor
      • Adalimumab (Humira) – TNF-α Inhibitor
      • Golimumab – TNF-α Inhibitor
      • Vedolizumab – Anti-Integrin Ab
      • Tofacitinib – Janus Kinase Inhibitor (Increased Risk of VTE – Second Line)
    • Infection Control: Cipro/Flagyl
  • Maintenance: 5-Aminosalicylic Acid (Sulfasalazine/Mesalamine)
    • Oral and/or Rectal (Topical/Suppository/Enema)

Management of Dysplasia

  • Definitions:
    • Visible – Found on a Targeted Biopsy of a Visible Lesion
    • Invisible – Found on Random Biopsy with No Visible Lesion
  • Visible Dysplasia:
    • Completely Excised: Continue Endoscopic Surveillance
    • Not Completely Excised: Proctocolectomy
    • If There is Any Invisible Dysplasia in the Surrounding Flat Mucosa: Proctocolectomy
  • Invisible Dysplasia: Repeat Colonoscopy in 3-6 Months by an Experienced Endoscopist
    • Should Be High-Definition with Chromoendoscopy (Uses Optic Filters or Contrasts/Dye Agents to Better Differentiate Abnormal Mucosa)
    • Indications for Total Proctocolectomy After Repeat Exam:
      • Invisible Multifocal Low-Grade Dysplasia
      • Invisible High-Grade Dysplasia
  • *Historically ANY Dysplasia was an Indication for Total Proctocolectomy – Changed in ASCRS 2021 Recommendations

Surgery Indications

  • Emergent Surgery:
    • Refractory Fulminant Colitis
    • Perforation
    • Massive GI Bleed
    • Toxic Megacolon
  • Elective Surgery:
    • Medical Intractability (Not Tolerated or Getting Worse) – Most Common Indication
    • Obstruction
    • Malignancy
    • Failure to Thrive in Children – Most Common Extraintestinal Indication

Surgical Treatment

  • Emergent: Total Abdominal Colectomy & End Ileostomy
    • Open if Megacolon Present
    • Second Stage Completion Proctectomy & Ileal Pouch Anal Anastomosis When Stabilized
  • Elective: Total Proctocolectomy & Ileal Pouch Anal Anastomosis
    • IPAA Will Have ≥ 5-6 BM’s Daily
    • Indications for End Ileostomy:
      • Poor Sphincter Function
      • Poor Mobility
      • Lifestyle/Occupation Not Permitting Frequent BM’s
      • Malnourished or Immunocompromised
    • May Be Completed in Stages:
      • One-Stage
        • 1. Total Proctocolectomy & IPAA (No Ostomy)
      • Two-Stage
        • 1. Total Proctocolectomy, IPAA & Loop Ileostomy
        • 2. Ileotomy Takedown
      • Three-Stage
        • 1. Subtotal Colectomy & End Ileostomy
        • 2. Proctectomy, IPAA & Loop Ileostomy
        • 3. Ileostomy Takedown
    • Protect Bladder/Sexual Function
    • Need Lifetime Surveillance
    • Most Common Complication: Leak

Extraintestinal Manifestations After Colectomy

  • Manifestations that Improve:
    • Erythema Nodosum
    • Arthritis
    • Eye Problems
  • Manifestations that Improve for Some (50%):
    • Pyoderma Gangrenosum
  • Manifestations that Do Not Improve:
    • Primary Sclerosing Cholangitis
    • Ankylosing Spondylitis

Inflammatory Bowel Disease (IBD) Comparison

Chrohn’s Disease

Inflammatory Bowel Disease Type Unspecified

Comparison

References

  1. Wikimedia Commons. (License: CC BY-4.0)
  2. Norsa AH, Tonolini M, Ippolito S, Bianco R. Water enema multidetector CT technique and imaging of diverticulitis and chronic inflammatory bowel diseases. Insights Imaging. 2013 Jun;4(3):309-20. (License: CC BY-4.0)
  3. Parameswaran S, Singh K, Nada R, Rathi M, Kohli H, Jha V, Gupta K, Sakhuja V. Ulcerative colitis after renal transplantation: A case report and review of literature. Indian J Nephrol. 2011 Apr;21(2):120-2. (License: CC BY-NC-SA-3.0)
  4. Haggstrom M. Wikimedia Commons. (License: CC0 1.0)