Ulcerative colitis is an idiopathic inflammatory disease of the colon and rectum characterized by severe ulcerative lesions and remissions. It typically involves the rectum and extends proximally through all or parts of the colon. Treatment involves medications to reduce inflammation like 5-aminosalicylic acid and immunosuppressants. Surgery may be required for complications or intractable cases.

1. Ulcerative colitis
Ulcerative colitis (UC)

Idiopathic inflammatory disease of the mucosa of colon and rectum
characterized by severe ulcerative lesion, going on with remissions and
exacerbations.

usually involves the rectum and extends proximally to involve all or
part of the colon.

Approximately 40 to 50% of patients have disease limited to the
rectum and rectosigmoid, 30 to 40% have disease extending beyond the
sigmoid but not involving the whole colon, and 20% have a total colitis.
EPIDEMIOLOGY
The incidence of UC varies within different geographic areas.
Northern countries, such as the United States, United Kingdom, Norway,
and Sweden, have the highest rates.
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The incidence rate is 4 - 20 cases per 100 000 year,
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The male to female ratio for UC is 1:1
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The peak age of onset of UC is between 15 and 30 years. A second
peak occurs between the ages of 60 and 80.
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ETIOLOGY
Although UC has been described as a clinical entity for over 100 years, its
etiology and pathogenesis have not been definitively elaborated.
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Genetic considerations
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Changes in the diet
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Infection
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Autoimmune inflammation
Clinical presentation.
Specific:
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Rectal bleeding;
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diarrhea with blood, pus and mucus ,
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Bowel movements 4 – 20 day ;
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Tenesmus or urgency with a feeling of incomplete evacuation ;

2. crampy abdominal pain
General:
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Fever;
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Dicreased appetitis;
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Weight loss.
Extraintestinal manifestations (20% cases):
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Joints - mono- or oligoarthritis, Ankylosing spondylitis
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Eyes - iritis, uveitis, conjunctivitis, episcleritis;
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Skin - Erythema nodosum, Pyoderma gangrenosum;
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Oral cavity - mouth ulcers;
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liver - Hepatic steatosis, Primary sclerosing cholangitis.
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kidneys -glomerulonephritis
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N.B. In some cases those lesions may precede the appearance of GI
symptoms.
Classification
By localization:
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Proctitis(distal colitis)and proctosigmoiditis
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Left-sided colitis
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Extensive colitis
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Pancolitis
By course:
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Acute ulcerative colitis
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Chronic ulcerative colitis
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Recurring ulcerative colitis
By severity of status:
Mild
Moderate
severe
Diagnosis.
1)Rectal exam :

3. perianal abscesses ,
Anal fistulas,
anal fissures ,
Spasm of sphincter, granular surface and thickening of mucosa,
Rigid wall,
Presence of blood, mucus, pus.
2)Sigmoidoscopy Proctoscopy
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With mild inflammation, the mucosa is erythematous and has a fine
granular surface that looks like sandpaper. In more severe disease, the
mucosa is hemorrhagic, edematous, and ulcerated .
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mucosal granularity ;
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Significant amount of blood, mucus, pus;
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Edema and hyperemia of sigmoid and rectal mucosa;
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Loss of haustration ;
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superficial erosions and ulcers , covered with pus and fibrin;
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Edema and excessive epithelial regeneration with pseudopolyps
formation.
3)Endoscopy
Minimal activity, (granular)
Moderate activity, (ulcerative).
Moderatesevere activity, (ulcerative).
Remission: pseudopolyps
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Lab tests:
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Increased ESR,
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Leukocytosis ,
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Increased platelet count ,
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Hypochromic anemia,
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Hypokalemia,
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Hypo- and dysproteinemia
Diagnosis
Microbiology.
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dicreased Lactobacillus bifidus to 61% (normally to 98%);
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Significant increasing of colibacilli and Enterococci;
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Growth of pathogenic Staphilococci (more than 60 times than norm);

4. •
Dyslocation of intestinal microflora up to the stomach.
Complications .
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Perianal lesions: anal fissures, perianal abscesses, or hemorrhoids (430%).
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Obstructions (benign stricture; one-third of the strictures occurring in
the rectum ). (3-19 %)
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Perforation of the colon (3-5%)
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Massive hemorrhage . (1-3%)
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Toxic megacolon (Acute toxic dilation of the colon) (3-5%)
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Malignancy. Patients with pancolitis have a 10% incidence of colon
cancer at 10-20 years with an additional 10% incidence for every decade
thereafter.
Goals of treatment
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Improvement of quality of life;
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Diminish the severity of symptoms;
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Prophylaxis of relapses.
Diet ( № 4)
To exclude:
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Milk and all dairy products;
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Fresh bread, bakery, sweets;
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Vegetable oil;
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cereals;
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All vegetables and fruits;
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Pickled food, marinades, spices;
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Fried food
Glucocorticosteroids
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Prednisone 60 mg/day
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Hydrocortisone 100 mg/day (enema )
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Beclometasone 200 – 1600 µg/day,
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Budesonide 200 – 800 µg/day
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Fluticasone 100 – 500 µgday

5. Sulfasalazine-(anti-inflam act)
(sulfapyridine + 5-aminosalicylic acid )
Sulfasalazine 4-6 gday
Side effects (dose > 4g /d):
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nausea,
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Abdominal pain,
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anorexia ,
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rash ,
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diarrhea,
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weakness,
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Agranulocytosis,
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allergic reactions .
5-aminosalicylic acid (5-ASA)
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In tablets (1,5-4 g)
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In suppositories (0,5 - 1,5 g/d)
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In enemas (4 g),
Аntibiotics
Despite numerous trials, antibiotics have no role in the treatment of active
or quiescent UC. However, pouchitis, which occurs in about a third of UC
patients after colectomy and ileal pouch-anal anastamosis, usually responds
to treatment with metronidazole or ciprofloxacin.
Immunosupressors

Cyclosporine 4 mg/kg IV or 10 mg/kg PO.

Azathioprine ,

6-Mercaptopurine
Newer Medical Therapies

5-lipooxygenase inhibitor (Cyleiton).
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Infliximab 10 mg/kg IV (chimeric mouse-human monoclonal
antibody against TNF )

6. Maintenance Therapy
Glucocorticoids play no role in maintenance therapy
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Sulfasalazine 2 gday
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5-АSA 0,75 - 1 gday PO
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Rectal forms of sulfasalazine and 5-ASA
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6-MP or azathioprine
Medical Management of Ulcerative Colitis: Active Disease
Indications for Surgery
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Intractable disease
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Fulminant disease
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Toxic megacolon
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Colonic perforation
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Massive colonic hemorrhage
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Extracolonic disease
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Colonic obstruction
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Colon cancer prophylaxis
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Colon dysplasia or cancer
Treatment of toxic megacolon:
1.Absolute cancellation of oral and rectal drugs intake, total parenteral
nutrition. Nothing by mouth.
2. Glucocorticosteroids (100 mg q6h), broad-spectrum antibiotics
(metronidazole or ciprofloxacin) IV.
3. Nasogastric suction.
4. Persistent follow-up (fever, abdominal pain, tension of abdominal wall,
diuresis, leukocytosis).
5. Radiographic control after colon dilation.
6. Indications to urgent operation: GI bleeding, perforation, uneffective
conservative treatment (during 1–3 days).
7.Anticholinergic and opioid drugs should not be used because they can
precipitate or aggravate toxic megacolon.

7. Maintenance Therapy
Glucocorticoids play no role in maintenance therapy
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Sulfasalazine 2 gday
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5-АSA 0,75 - 1 gday PO
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Rectal forms of sulfasalazine and 5-ASA
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6-MP or azathioprine
Medical Management of Ulcerative Colitis: Active Disease
Indications for Surgery
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Intractable disease
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Fulminant disease
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Toxic megacolon
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Colonic perforation
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Massive colonic hemorrhage
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Extracolonic disease
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Colonic obstruction
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Colon cancer prophylaxis
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Colon dysplasia or cancer
Treatment of toxic megacolon:
1.Absolute cancellation of oral and rectal drugs intake, total parenteral
nutrition. Nothing by mouth.
2. Glucocorticosteroids (100 mg q6h), broad-spectrum antibiotics
(metronidazole or ciprofloxacin) IV.
3. Nasogastric suction.
4. Persistent follow-up (fever, abdominal pain, tension of abdominal wall,
diuresis, leukocytosis).
5. Radiographic control after colon dilation.
6. Indications to urgent operation: GI bleeding, perforation, uneffective
conservative treatment (during 1–3 days).
7.Anticholinergic and opioid drugs should not be used because they can
precipitate or aggravate toxic megacolon.