ULCERATIVE COLITIS DEFINITION It is an inflammatory condition of rectum & colon of unknown aetiology perhaps related to stress, westernized diet, autoimmune factor, familial tendency, allergic factor. commonly starts in the rectum, spreads proximally to the colon & often into the ileum as back wash ileitis (5%).

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ULCERATIVE
COLITIS

2. ULCERATIVE
COLITIS

3. ULCERATIVECOLITIS
DEFINITION
• It is an inflammatory
conditionof rectum& colon
of unknownaetiology
perhaps related to stress,
westernized diet,
autoimmune factor, familial
tendency, allergic factor.
• commonly starts in the
rectum, spreads proximally
to thecolon& oftenintothe
ileumas back wash ileitis
(5%).

4. AETIOLOGY
• Westernized diet
• red meat
• Defective mucinproduction
in the colonic mucosaand
mucosal immunological
reaction.
• Autoimmune factors—
cytotoxicT lymphocytes
against colonicepithelial
cells& presence of anti-
colon antibodies.
• Association with HLA DR2
is observedin ulcerative
colitis.
• DR 1501 is associated with
less severe type’
• DR 1502 is associated with
more severe form.
• Appendicectomy &
smoking protects ulcerative
colitis especially from
extraintestinal features
and frompostoperative
complications.

5. • Allergy to milk(cow milk)
and other dietaryfactors.
• Excessreactive oxidative
metabolismin ulcerative
colitis.
• Psychological aspects
• Stress
• Lifestyle
• Personality disorders
PATHOLOGY
To begin with, multiple minute
ulcers (pinpoint ulcers) occur
with proctitis and colitis
↓
Theseulcers extendintothe
deeper layer
↓
Spasmof the bowel
↓
Stricture of the colon↓
Permanently contractedcolon
(pipe stemcolon)

6. ↓
In between ulcers, epithelial
thickening occurs which
appears likepolyps –
Pseudo polyposis
↓
It is confined to mucosaand
submucosa.
↓
no bowel wall thickening
and no granuloma
formation& no skiplesions.
↓
Rectumis alwaysinvolved,
thenspreads proximally.
↓
Entire colonincluding
caecumand appendix may be
involved.
↓
Proctitis occurs in 25%cases.
↓
5%risk of developing rectal
cancer
↓
In 15% left sided ulcerative
colitis presenting withsevere
recurrent diarrhoea.

7. ↓
In 25%patients, total
proctocolitis is the presentation.
↓
Bloody diarrhoea,
Malnutrition.
↓
complications like toxic
megacolon, perforation (steroid
may maskthe features) and
carcinoma are common here.
↓
Pseudo polyps are of
inflammatoryin nature.
↓
Absence of normal mucosa
betweenthesepseudo
polyps is importantto
differentiate it from
neoplastic polyps.
↓
Multiple crypt abscesses
↓
Sparing of the deeper
layersof the colonicwall
↓
Inflammatory
pseudopolyps
↓

8. Multiple pinpointulcers
Increase in substance p
containing nerve fibres
↓
Lymphoidhyperplasia in
mucosaand submucosa
↓
Presence of anti neutrophil
cytoplasmic antibodies with
a perinuclear staining
pattern
↓
Decreasedgoblet cell
mucin
↓
Only in toxic megacolon-
there is acuteinflammation
extending to entire thickness
of the colonicwall including
the serosa.
↓
It is precipitatedby non
specificcauses, during
bariumenema study, due to
drugs like opiates,
antidiarrhoeal drugs and
anticholinergics.
↓

9. Toxic megacolon commonly
affects the transversecolonwhich
will be more than6 cm in
diameter.
↓
Left colon or entire colon also may
be involved.
↓
Caecumwhenrarely involved;
becomes more than10 cm in
diameter.
↓
Colonwill be likewet
blotting paper
↓
Carcinoma in ulcerative
colitis is more prevalent than
in Crohn‘s disease.

10. FACTORS INVOLVEDARE
• Extent of involvement (more
in total colonic)
• Durationof the disease;
continuous active disease
thanintermittent disease.
• Dysplasia developing into
cancer is common.
• Ulcerative colitis with
primary sclerosing
cholangitis has still
increasedriskof
developing cancer.
• In ulcerative colitis,
dysplasia is very
importantfactor to
transforminto
carcinoma.

11. INCIDENCE
• Incidence of carcinoma is
equal in both sexes.
• Carcinoma in ulcerative
colitis is commonly
aggressive
• poorlydifferentiated
• Multicentric
• Synchronous
• infiltrative & scirrhous
• half the patients will
havecolloid carcinoma
(signet ring)
CLINICALFEATURES
• Disease usuallybegins in
rectumas proctitis later
becomes left sidedcolitis
and eventually causes
severetotal proctocolitis.
• Waterydiarrhoea, mucus
or blood staineddis
charge per rectum.
• Colickypain, spasms.
• Decreasedappetite and
loss of weight.
• Relapses and remissions
at regular intervals

12. TYPES
a. Fulminanttype
• 5%common
• It is a severe form, with
continuous diarrhoea
withpassage of blood,
mucus and pus.
• Mimics fulminant
amoebic colitis
• severe typhoid
• Dysentery
• Fever
• Hypokalaemia
• Acidosis
• Dehydration
• Shock
• Abdominal distension
occurs
• Acute toxic dilatation of
transversecolon may
occur wherethe diameter
of transversecolon >6 cm.
• requires surgery
• i.e. either colostomyor
resection withileostomy
and later illeo-anal
anastomosis.
• Here colon is likewet
blotting paper.

13. b. Chronictype
• 95%common
• Lasts for months to
years
• withdiarrhoea
• blood loss
• Anaemia
• Invalidism
• abdominal discomfort
• pain.
• Severe malnutrition
• hypoproteinaemia
INVESTIGATION
• Bariumenema shows loss of
haustrations
• Narrowcontracted
colon (hose pipe colon)
• Mucosal changes
• Pseudo-polyps.
• Sigmoidoscopy &
biopsy.
• Colonoscopy is also required.
• High incidence of malignant
transformation - multiple
biopsies should be taken

14. DIFF. DIAGNOSIS
• PlainX-rayabdomenis
useful in obstruction
• toxicmegacolon
• perforation.
• C-reactive proteinwill be
very highin acutephase.
• Crohn’s disease™
• Ischaemiccolitis ™
• Irritable bowel syndrome ™
• Amoebiccolitis™
• Bacillary dysentery ™
• Carcinoma colon™
• Collageous colitis in
females ™
• Infectious colitis by
Clostridiumdifficile,
Campylobacterjejuni

15. COMPLICATION
GIT ™
• Pseudopolyposis ™
-
Turning into malignancy ™
• Stricture formation
• Toxic megacolonin
transversecolon ™
• Massive haemorrhage
• Fistula in ano
• Perforation
Extraintestinal ™
• Severe malnutrition™
• Liver cirrhosis ™
• Skin lesions
• pyoderma,
• Erythema nodosum™
• Arthritis
• Iritis
• Ankylosing
spondylitis
• Sclerosing
cholangitis
• Carcinoma of bile
duct

16. TREATMENT
• Correctionof anaemia ™
• Fluid and electrolyte
supplimentation™
• Nutrition
• highprotein
• Carbohydrate
• Vitamin
• but low fat diet
• TPN™
Sedatives and
tranquillisers ™
• Psychological counselling
INDICATIONS OF SURGERY
• Intractability—
commonest indication™
• Toxic dilatation ™
• Perforation™
• Haemorrhage ™
• Risk of malignant
transformation
• Dysplasia (DALM) ™
• Onset at earlyage ™
• Chronicinvalidism™

17. • Progressive disease with
• Stricture
• Abscess
• Fistulae ™
• Steroiddependency,
• Persistent active disease™
• Malignancy ™
• Severe extraintestinal
manifestations ™
• Growth retardationin
children
SURGERY
• Total proctocolectomy with
ileo-anal anastomosis with
pouches as reservoir (“J’, ’S’,
or “W’ pouches). I
• It is called as restorative
proctocolectomy withileal
pouchanal anastomosis
(IPAA).
• It is ideal curative
procedurefor ulcerative
colitis.

18. • Total proctocolectomy
with ileostomy
(permanent, continent
Kock’s ileostomy, with one
way valve is done)
• Total proctocolectomy
with end non continent
ileostomy was the earliest
operation done for
ulcerative colitis.
REFERENCE
1. SRB's Manual of Surgery
by SriramBhatM
2. A Manual on Clinical
Surgeryby Das
3. A Concise textbookof
Surgeryby Das

19. A
Special Thanks
To A Very
Special Doctor