This document summarizes ulcerative colitis (UC), including its causes, pathology, symptoms, complications, investigations, and treatment. Some key points: - UC is an inflammatory bowel disease affecting the rectum and colon. The causes are largely unknown but there is a clear genetic contribution. - Pathologically, UC causes diffuse superficial inflammation starting in the rectum and extending proximally. Histology shows inflammatory cells in the lamina propria and crypt abscesses. - Symptoms include rectal bleeding, tenesmus, and mucus discharge. Complications include toxic dilatation, perforation, hemorrhage, and colon cancer. - Treatment involves 5-aminosalicy

1. By Dr. Ye Htet Aung

2. • UC is a disease of the rectum and colon
with Extra-intestinal manifestations.

3. Aetiology
Causes - ????

4. UNKNOWN

5. • There is clearly a Genetic Contribution
– 10-20% of patients have first degree
relatives of IBD

6. • UC
– More common in Caucasians than Asians
and AfroCaribbeans
– No causative link with any specific
organisms

7. – Others
• Smoking seems to have protective effects
• Patients’ comments – relapses are
associated with stress at home or at work
• But personality and psychiatric profiles
are the same as those of normal
porpulation.

8. Pathology
• Virtually all cases,
– Disease starts in the Rectum and
– Extends proximally.
• Rectal sparing
– Only in those using topical rectal
preparations

10. • Colonic inflammation
– Diffuse, confluent and superficial
– Affecting mucosa and submucosa
– Severe cases – affecting full thickness of the
colon

11. • Chronic mucosal ulceration
– Formation and regeneration of granulation
tissue leading to a polyp-like appearance
– Pseudo-polyps
• Stricture – unusual in UC

13. • Histology
– Inflammatory cells in Lamina propria
– Crypt abscess
– Depletion of goblet cell mucin
– With time – dysplasia

15. Symptoms
• Main Symptoms
– Rectal Bleeding
– Tenesmus
– Mucous discharge
• Pain is Unusual

16. • Others
– Extensive cases – extra-intestinal
manifestations
– Anaemia, Hypoprotinaemia and Electrolytes
imbalance due to Diarrhea

17. Proctitis
•
•
•
•
50% have rectal inflammation
Troubles – tenesmus and urgency
No systemic upsets
5-10% involves the rest of the colon

18. Colitis
• Clinical patterns –
– Bloody diarrhoea up to 20 times
– Dehydration
– Fluid and electrolytes imbalance
– Anaemia
– hypoproteinaemia

19. • Diarrhoea indicates active disease
proximal to the rectum
• Increased tendency to systemic upsets
• Bleeding --- Protien loss --- Weight loss
• Greater risk of extra-intestinal
manifestation and cancer
• 30% - inflammation extending up to
Sigmoid colon
• 20% - Up to splenic flexure

20. Colitis Severity Classification
• Mild
• Moderate
• Severe
• Fulminant

21. • Mild
– fewer than 4 stools daily
– With or without bleeding
– No systemic signs and symptoms
– ESR - normal

22. • Moderate
– More than 4 stools daily
– Fewer signs of systemic illness
– Mild anaemia
– Abdominal pain may be present
– Raised ESR and CRP

23. • Severe
– More than 6 bloody stools per day
– Systemic illness – fever, tachycardia,
anaemia
– Raised Inflammatory markers
– Hypoalbuminaemia is common

24. • Fulminant disease
– More than 10 bowel movements daily
– Fever, tachycardia, continuous bleeding,
anaemia
– Hypoalbuminaemia
– Abdominal tenderness and distension
– Progressive colonic dilation(Toxic Mega
Colon)
• Very significant finding
• Indication for immediate surgery to avoid
perforation

25. Extra-intestinal manifestations
• Arthritis
– 15% of patients
– Large joint polyarthropathy type
– Affecting knees, ankles, elbows, wrists
– Sacroiliatis and ankylosing spondylitis are
20 times common than general population

26. • Sclerosing cholangitis
– Progress to cirrhosis and hepatocellular
failure
• Skin lesions
– Erythema nodosum and pyoderma
gangrenosum
• Eyes
– Uveitis and episcleritis

27. Complications of UC
• Acute
– Toxic dilatation
– Perforation
– Haemorrhage

28. • Chronic
– Cancer
– Extra-alimentary manifestations
• Skin lesions,
• eye problems,
• liver diseases

29. Acute colitis
• Fulminating colitis and toxic dilatation
( megacolon)
• 5-10%
• Present with
– Severe bowel symptoms
– Dehydration and systemic upset

30. • Dilatation
– Suspected in acute colitis with severe
abdominal pain
– Plain X-ray abdomen showing colon with a
diameter of more than 6 cm
• Plain abdominal radiographs should be
obtained daily in patients with severe
colitis,
• A progressive increase in diameter in
spite of medical therapy is an indication
for surgery

31. Perforation
• Colonic perforation in UC is grave
complication.
• Mortality – 40%
• Perforation sometimes may occur
without dilatation

32. Haemorrhage
• Severe rectal bleeding is uncommon
• Occationally require transfusion
• Rarely surgery

33. Investigations

34. Endoscopy and Biopsy
• Rigid/Flexible sigmoidoscopy
– Can detect proctitis
– Mucosa – hyperaemic , bleed on touch, purulent
exudate
– Presence of regenerative mucosal nodules or
polyps

36. • Colonoscopy and biopsy
– Key role in Dx & Mx of UC
– To establish the extent of inflammation
– To distinguish between UC and CD
– To monitor the treatment of Disease
– To assess long-standing case for malignant
change

37. UC
CD
Macroscopic
Distribution
Colon/ Rectum
Rectum
Perianal disease
Fistula formation
Stricture
Always involved
Rare
Rare
Rare
Anywhere in the GI
tract
Often spared
Common
Common
Common
Mucosa/submucosa
No
No
Common
Full thickness
Common
Common
Rare
Microscopic
Layer involved
Granulomas
Fissuring
Crypt abscess

39. Radiology
• Plain abdominal film
– Indicates severity of disease in acute setting
– Valuable in demonstrating toxic mega colon
– Small bowel loops in RHC – sign of severe
disease

41. • Barium Enema
– Gives excellent view of loss of haustra , especially
in the distal colon, pseudopolyps
– Chronic cases – narrow, shorten, featureless
‘hosepipe’ colon.

43. • CT
– Pancolitis – significant thickening of colonic wall

45. Bacteriology
• To exclude infective colitis

47. Treatment
• Effective management of UC requires
multidisciplinary approach.
• Involves gastroenterologist, nurses,
nutritionist, enterostomal therapists and
occasionally clinical psychologists and
social workers, as well as the surgeon

48. Medical Treatment
• Based on anti-inflammatory agents
• Non-specific anti-diarrhoeal agents have
no place in the routine management of
UC
• 5-aminosalicylic acid (5ASA) derivatives
such as Mesalazine
– Topically (per rectum)
– Systemically
• Can be used long term as maintainance

49. • Corticosteroids
– Topically
– Systemically
• Mainstay treatment for any “Flare-up”

50. Tx of Proctitis
• Acute attack – rectal steroids
• To maintain remission – 5-ASA
compounds
• Surgery – very unusual for purely rectal
disease

51. Acute colitis
• Mild attack
– respond to oral steroids over 3-4 weeks
period. One of 5- ASA can be given together.
• Moderate attack
– Oral Steroid + 5-ASA + twice daily steroid
enema

52. • Severe attack
– Emergency
– Requires admission
– Stool chart and
– Plain X-ray abdomin daily for toxic mega
colon
– Anaemia – correct
– Fluid and electrolytes – balance
– Nutrition
– I.V. Hydrocortisone four times daily as well
as rectal steroid

53. – No evidence that antibiotics modify the
course of severe attack
– If no improvement within 48 hours of high
dose steroids,
– Surgery should be seriously considered
– Advisable at day 3-5
– Some Gastroenterologists give azathioprin,
cyclosporin A and infliximab to induce
remission in severe attack

54. Operative Treatment
• Emergency
• Elective

55. Emergency
• First Aid Procedure
– Sub-total colectomy and end ileostomy

56. Elective
• Subtotal colectomy and end ileostomy
• Protocolectomy and permanent end
ileostomy
• Restorative protocolectomy with ileoanal
pouch
• Subtotal colectomy and ileo-anal
anastomosis

57. Differences between
Ulcerative colitis and
Crohn’s disease

58. • Ulcerative colitis affects the colon;
Crohn’s disease can affect any part of the
gastrointestinal tract, but particularly the
small and large bowel
• UC is a mucosal disease, whereas CD
affects the full thickness of the bowel
wall

59. • UC produces confluent disease in the
colon and rectum, whereas CD is
characterized by skip lesions
• CD more commonly causes stricturing
and fistulation

60. • Granulomas may be found on histology in
CD, but not in UC
• CD is often associated with perianal
disease, whereas this is unusual in UC
• CD affecting the terminal ileum may
produce symptoms mimicking
appendicitis, but this does not occur in UC

61. • Resection of the colon and rectum cures
the patient with UC, whereas recurrence
is common after resection in CD