This document provides an overview of ulcerative colitis, including its epidemiology, pathology, clinical features, investigations, classifications, complications, extraintestinal manifestations, and treatments. Ulcerative colitis is a type of inflammatory bowel disease that causes inflammation and ulcers in the lining of the large intestine. It typically affects the rectum and lower colon. The cause is unknown but believed to involve genetic and environmental factors. Symptoms can range from mild to severe and include abdominal pain, bloody diarrhea, and weight loss. Diagnosis involves endoscopy and biopsy. Treatment includes medications to reduce inflammation as well as colectomy surgery in severe cases.

1. Dr. Dinesh. M.G
Professor of Surgery
J.J.M.M.C.
Davangere

2. Introduction
 Inflammatory bowel disease is reserved for the conditions
characterised by idiopathic intestinal inflammation, i.e.
ulcerative colitis and Crohn’s disease
Ulcerative colitis
 Ulcerative colitis is disease of the rectum & colon unlike
Crohn’s which can involve any part of GI tract with
extraintestinal manifestations
 Incidence: 10 per 1 lakh population in UK
 Prevalence: 160 per 1 lakh in UK
 Males are affected more
 Less common in Asia

3. Ulcerative colitis
Aetiology
 Exact cause is not known
 Multifactorial and polygenic
 Environmental factors
 Immune dysfunction
 Genetic predisposition
 Western diet
 Stress
 Smoking has protective effect

4. Ulcerative colitis
Pathology
 In all cases the disease starts in rectum and extends
proximally in continuity
 Colonic inflammation is diffuse, confluent and superficial
affecting mucosa and superficial submucosa
 Full thickness of wall is involved in severe cases of
inflammation
 Chronic mucosal ulceration with regeneration leads to
‘pseudopolyposis’
 Back wash ileitis involving terminal ileum may develop
due to incompetent ileocaecal valve

5. Ulcerative colitis-Pathology
 Microscopically there are inflammatory cells in lamina
propria and crypt abscesses
 Depletion of goblet cell mucin
 Precancerous dysplastic changes appear in mucosa over
period of time
Clinical features
 Depends on extent of disease and presence of complications
 In proctitis alone there is no systemic upset and extraintestinal
manifestations are rare

6. Ulcerative colitis-clinical features
 Rectal bleeding, tenesmus and mucous discharge
 Colitis is associated with bloody diarrhoea and urgency
 Impaired growth in children
 Extensive colitis has:
 Malaise
 Loss of appetite
 Fever
 Anaemia, hypoproteinaemia and electrolyte disturbance

7. Ulcerative colitis
Classification of colitis severity
 Mild disease
 < 4 stools/day with or without bleeding
 No systemic signs of toxicity
 Normal ESR
 Moderate disease
 4-6 stools/day with few signs systemic illness
 Abdominal pain
 Raised ESR, raised C-reactive protein

8. Ulcerative colitis
 Severe disease
 >6 bloody stools/day
 Systemic illness with fever, tachycardia, anaemia, and raised
inflammatory markers
 Hypoalbuminaemia
 Fulminant disease
 >10 stools/day
 Fever, tachycardia, continuous bleeding, anaemia,
hypoalbuminaemia
 Abdominal tenderness and distension
 ‘Toxic megacolon’ necessitating immediate surgery

9. Complications of ulcerative colitis
 Acute
 Toxic dilatation
 Perforation
 Haemorrhage
 Chronic
 Cancer
 Extraintestinal manifestations:
 Arthritis
 Liver disease
 Skin lesions
 Eye problems

10. Ulcerative colitis
Extraintestinal manifestations
 Arthritis
 Polyarthropathy affecting knees, ankles, elbows and wrists
 Sacroileitis
 Ankylosing spondylitis
 Liver
 Sclerosing cholangitis
 Cholangiocarcinoma
 Skin lesions
 Erythema nodosum
 Pyoderma gangrenosum
 Eye lesions
 Uveitis
 Episcleritis

11. Ulcerative colitis
Clinical presentation
Acute or fulminant type
 Affects 5% characterised by
 Frequent bloody diarrhoea
 Weight loss
 Dehydration
 Toxic megacolon should be suspected when patient complains
of severe abdominal pain with distension
 About 30% of cases require urgent surgery
Chronic type
 Lasts for months to years with diarrhoea, blood loss, anaemia,
abdominal pain
 Severe malnutrition and hypoproteinaemia

12. Ulcerative colitis-Investigations
 Endoscopy and biopsy
 Colonoscopy for diagnosing, monitoring and detection of
malignant change
 Mucosa is hyperaemic & bleeds on touch
 Purulent exudate
 Pseudopolyps
 Radiology
 Plain x-ray
 Toxic megacolon(transverse colon diameter >6cms)
 Barium enema
 Loss of haustrations
 Pseudopolyposis
 Long standing cases leading to shortened ‘lead pipe’ colon

13. Colonoscopy
Pseudopolyposis

14. Barium enema
Lead pipe colon Left sided colitis

15. Treatment
 General
 Correction of anaemia
 Fluid & electrolyte supplementation
 Nutrition
 High protein, carbohydrate, vitamin and low fat
 Sedatives and tranquilisers
 Psychological counselling

16. Treatment
 Drugs
 Salazopyrin/ sulfasalazine
 Splits into 5ASA & sulphapyridine in colon- dose 2-4g/day
 5 ASA(mesalamine)
 oral dose of 2-4g/day or retention enema 4g/100ml
 Steroids
 Oral prednisolone 60mg/day tapering in 4 wks
 I.V. hydrocortisone 100mg 8 hourly in acute cases
 100mg hydrocortisone or 40mg methylprednisolone enema for 2 wks
 Immunomodulators
 Azathioprine
 6-mercaptopurine
 Cyclosporin
 Antitumour necrosis factor alpha-Infliximab

17. Treatment
 Indications for surgery
 Failure of medical therapy/steroid dependence
 Growth retardation in the young
 Extraintestinal disease
 Malignant disease
 Operations
 Subtotal colectomy with ileostomy(emergency)
 Proctocolectomy with ileostomy
 Proctocolectomy with ileoanal pouch
 Colectomy with ileorectal anastomosis

18. Surgical treatment
Proctocolectomy with ileostomyProctocolectomy with ileoanal pouch
Colectomy with ileorectal anastomosis

20. Colonic diverticular disease
 Types of intestinal diverticula
 Congenital (True): All three coats of bowel are present
 e.g. Meckel’s diverticulum
 Acquired (False): No muscular coat in the diverticulum
 e.g. Sigmoid diverticula
 Colonic diverticula are acquired herniation of colonic mucosa
through circular muscles at the points of entry of blood vessels
 Sigmoid is commonly affected(80%)
 Does not occur in rectum
 Common in West.
 Rare in Asia and Africa

21. Diverticular disease of colon

22. Colonic diverticula
Aetiology
 Low fibre diet
 More common in females and old age
 Diverticulosis is the primary stage where there is
hypertrophy, muscular incoordination, increased
segmentation
 Often at this stage patients are asymptomatic but
occasionally get severe spasmodic pain due to
segmentation(painful diverticular disease)

23. Complications colonic diverticula
 Pain and inflammation(diverticulitis)
 Perforation leading to pericolic abscess or peritonitis
 Intestinal obstruction
 Haemorrhage
 Fistula formation
 Colovesical
 Colovaginal
 Enterocolic
 Colocutaneous

24. Colonic diverticular disease
Clinical features
 Mild cases
 Distension
 Flatulence
 Lower abdominal heaviness

25. Colonic diverticulitis
Clinical features
 Diverticulitis
 Persistent lower abdominal pain
 Loose stools/constipation
 Fever, malaise, and leucocytosis
 Tenderness in left iliac fossa
 Tender thickened sigmoid colon
 Tender mass on rectal examination if abscess has formed
 Diffuse abdominal pain, tenderness, guarding and rigidity in cases
of peritonitis
 Features of large bowel obstruction
 Haemorrhage can be typically painless and profuse
 Colovesical fistula presents with recurrent UTI, pneumaturia or
faeces in urine

26. Colonic diverticular disease
Classification of contamination
 Hinchey classification of complicated diverticulitis
 Investigations
 Barium enema
 Colonoscopy
 Plain x-ray erect abdomen for pneumoperitoneum
 CT scan
 Cystoscopy in cases of colovesical fistula
Grade I Pericolic or mesenteric abscess
Grade II Pelvic abscess
Grade III Purulent peritonitis
Grade IV Faecal peritonitis

27. Hinchey’s classification

28. Investigations-Barium enema

29. Investigations-CT scan

30. Colonoscopy

31. Colonic diverticular disease
Management
 High fibre diet
 Bulk laxatives
 Antispasmodics
 Antibiotics for acute diverticulitis
 Percutaneous drainage of abscess
Surgical management
 Indications
 Recurrent diverticulitis
 Generalised peritonitis

32. Colonic diverticular disease
Surgical management
 Emergency surgery
 Hartmann’s procedure(sigmoid colectomy with descending
colostomy and closure of rectal stump
 Sigmoid resection with end to end anastomosis with or
without defunctioning loop ileostomy
 Elective surgery
 Open or laparoscopic sigmoid resection with end to end
anastomosis
 Colovesical fistula needs resection of affected bowel
 Myotomy can be performed in early cases of diverticulosis

33. Surgical management

34. Thank you