Ulcerative colitis is a chronic inflammatory bowel disease that involves the colonic mucosa. It typically affects the rectum first and may extend proximally in a continuous manner. The disease runs a relapsing and remitting course. Treatment involves 5-aminosalicylates and corticosteroids to induce and maintain remission. For moderate to severe disease, immunosuppressants like azathioprine, anti-TNF agents, and vedolizumab may be used. Surgery with proctocolectomy and ileal pouch-anal anastomosis is the treatment of choice for those who require colectomy.

1. ULCERATIVE
COLITIS
DR. NIKHIL CHANDRA ROY

2. DEFINITION
 Chronic inflammatory condition
 Mucosal inflammation without granuloma
 Involvement of the rectum with variable proximal extension
 Continuous fashion
 Relapsing and remitting course

3. EPIDEMIOLOGY
 More common in western countries
 Onset: Peak age of onset 2nd and 3rd decade, second smaller peak at
60 and 70s
 Male >Female
 More common in nonsmokers and ex-smokers

4. ETIOLOGY
Genetic
Susceptibility
• - Family history
• - Genetic mutations
Environ
mental
Factors
• - Enteric infection
• - Microbial dysbiosis
• - Non/Ex-smoker
• - Dietary Factors
• - Drugs- NSAIDs, OCP
Host
Immunity
•-
•- Cell mediated Immunity
-Humoral immunity

5. PATHOLOGY
 Always involves the rectum with variable proximal extension
 Sharp transition between diseased and healthy segment of the colon
 Small intestine is normal, although mild mucosal inflammation of
distal ileum(backwash ileitis) may be present

6. MACROSCOPIC FEATURES
 Mucosa appears hyperemic, edematous and granular in mild disease
 Hemorrhage, with visible punctate ulcers
 Pseudopolyps
 Mucosal bridges
 In long standing disease, mucosal atrophy with a flat and smooth
mucosal surface that lacks normal folds(featureless colonic mucosa)

7. GROSS PATHOLOGY OF ULCERATIVE COLITIS
B. Sharp demarcation between active UC and normal mucosa
A Total colectomy with pancolitis showing active disease,
with red, granular mucosa in the cecum (left) and
smooth, atrophic mucosa distally (right).
C, Inflammatory polyps. D, Mucosal bridge

8. MICROSCOPIC FEATURES
 Clusters of neutrophils within a crypt (cryptitis, crypt abscesses)
 Architectural crypt distortion
 Inflammation generally confined to mucosa and superficial
submucosa
 Epithelial metaplasia

9. C. Disease is limited to the mucosa
MICROSCOPIC PATHOLOGY OF ULCERATIVE COLITIS
A. Crypt abscess.
B. Pseudopyloric metaplasia (bottom).
A
C
B

10. CLASSIFICATION
EXTENT ANATOMY
E1 Proctitis limited to rectum(Distal to rectosigmoid junction)
E2 Proctosigmoiditis or left
sided colitis
Affects the rectum and left colon( distal to splenic flexure)
E3 Pancolitis or extensive
colitis
Affects the rectum and colon proximal to splenic flexure
According to disease extent (Montreal classification)

11. CLASSIFICATION (according to disease severity)
SEVERITY
S0 Clinical remission
S1 Mild UC
S2 Moderate UC
S3 Severe UC

12. CLINICAL MANIFESTATIONS
Depends on extent and severity of the disease

13. ULCERATIVE PROCTITIS
 Rectal bleeding
 Rectal urgency
 Constipation
 Systemic features are uncommon but skin or joint symptoms can
occur

14. LEFT SIDED COLITIS
 Diarrhea or constipation
 Tenesmus, urgency, rectal bleeding
 Colicky left lower quadrant pain and extraintestinal manifestations
are more common than with proctitis

15. EXTENSIVE COLITIS
 Diarrhea
 Urgency, tenesmus, cramping abdominal pain
 Systemic features
o weight loss
oFever
oNight sweats
oNausea, vomiting

17. DIFFERENTIAL DIAGNOSES
 Crohn’s colitis
 Infectious colitis
 Ischemic colitis
 Radiation colitis
 Diverticulitis
 Microscopic colitis
 Pseudomembranous colitis
 Amoebic colitis
 Schistosomiasis
 Colon cancer
 NSAID enteropathy
 HSP, Behcet’s disease

18. LABORATORY INVESTIGATIONS
BLOOD TEST :
 CBC- anemia, leukocytosis, thrombocytosis ,high ESR
 Electrolytes
 Liver enzymes- minor elevation of AST and ALP
 S. albumin –To assess severity and prognosis
 Baseline kidney function
 CRP- Elevated in active UC

19. STOOL TEST
 Stool RE and CS: To exclude infectious colitis
 Assay for toxins A and B of C. difficile
 Fecal calprotectin is a marker of intestinal inflammation
o >250 mcg/g is predictive of relapse of UC
o < 50 mcg/g is predictive of remission

20. SEROLOGICAL MARKERS:
p-ANCA
ASCA
The combination of positive p-ANCA and negative ASCA
facilitate establishing a diagnosis of UC

21. COLONOSCOPY / SIGMOIDOSCOPY
 Colonoscopy contraindicated in severe UC
 Risk of perforation
 Risk of megacolon
 Risk of sedation
 Flexible sigmoidoscopy instead
 Minimal insufflation
 No/minimal sedation
 Limit exam to rectum
 No retroflexion

22. Findings
 Mucosal erythema and edema
 Loss of normal vascular pattern
 Mucosal granularity(fine or coarse)
 Coarse granularity represent microscopic or pinpoint ulceration, and
associated with friability(spontaneous or scope induced contact
bleeding)
 Ulcearation(usually shallow)
 Exudates of mucopus
 Pseudopolyps with long standing disease

23. Endoscopic assessment - severity

24. HISTOLOGY

25. HISTOLOGY
ACTIVE UC: Distorted colonic
crypts , inflammatory
infiltrate , crypt abcess
QUISCENT UC: Branched
colonic crypts but no active
inflammatory infiltrates

26. IMAGING STUDIES
 Plain X-Ray abdomen: useful in severe attack of UC
 Thumbprinting or thickening of colon wall severe colitis with
bowel edema
 Distended bowel with loss of haustration toxic megacolon
 Barium enema less commonly used
 Colon typically appears granular and shortened

28. • Barium Enema

29. ASSESSMENT OF DISEASE ACTIVITY
 There are numerous indices to measure disease activity in UC
 The truelove and Witts classification is reliable and simple to use in
clinical practice
 It is most applicable for patients with extensive colitis

30. Mild Moderate Severe
Bloody stool < 4 ≥ 4 if ≥ 6 and
Pulse < 90 ≤ 90 > 90
Temperature < 37.5 ≤ 37.5 > 37.5
Hemoglobin > 11.5 ≥ 10.5 < 10.5
ESR < 20 ≤ 30 > 30
CRP Normal ≤ 30 > 30
Truelove & Witts

31. Partial Mayo clinic Index
(PMI)

32. MANAGEMENT OF UC

33. MEDICAL THERAPY
The Rx Strategy for UC is mainly based on -
• Distribution (proctitis, left sided or extensive colitis)
• Severity(mild, moderate, severe)
• Prior therapy (response, side effect, compliance)

34. Indduction of remission in mildly active UC
Proctitis Left sided colitis Extensive colitis
Rectal 5-ASA(1g/d) • Rectal 5-ASA
enema(1g/d)
preferred over rectal
steroids
• Suggest rectal 5-ASA
enemas(1g/d)
combined with oral
5- ASA
(2g/d)compared with
oral 5-ASA alone
• Oral 5-ASA (2g/d)
If intolerant or nonresponsive to 5-ASA therapy, recommend oral budesonide MMX
9mg/d or oral systemic corticosteroid for induction of remission

35. Maintenance of remission in mildly active UC
Proctitis Left-sided or extensive UC
Rectal 5-ASA at a dose of at
least 1g/d
Recommend oral 5-ASA therapy at a dose at least
2g/d for maintenace of remission
Recommend against systemic corticosteroids for maintenance of remission in patient
with UC

36. Induction of remission for moderate to severe UC
Moderately active UC Moderately to severely active UC of any
extend recommended
Recommend oral budesonide MMX • Oral systemic corticosteroids
• Anti-TNF therapy in combination with
azathioprine
• Vedolizumab
• Tofacitinib 10 mg orally b.i.d. for 8 wks
Moderately to severe UC who have
previously failed anti-TNF therapy
recommend
• Vedolizumab
• Tofacitinib 10 mg orally b.i.d. for 8 wks

37. Maintenance of remission moderate to severe UC
• Recommend against systemic corticosteroids or MTX for maintenance
of remission
• Now in remission due to corticosteroids induction, suggest thiopurines
for maintenance of remission compared with no treatment or
corticosteroids. Recommend
• Continuing anti-TNF therapy to maintain remission after anti-TNF
induction
• Continuing vedolizumab to maintain remission after Vedolizumab
induction
• Continuing tofacitinib to maintain remission after Tofacitinib induction

38. MANAGEMENT OF HOSPITALIZED PATIENT WITH ACUTE SEVERE UC (ASUC)
• ASUC is defined as presence of 6 or more bowel movement plus 1
systemic sign of toxicity including tachycardia, fever, anemia
(Hb<10.5 gm/dl)or elevated inflammatory markers(ESR and CRP)
• All patients with ASUC should have stool testing to rule out CDI and
should undergo flexible sigmoidoscopy to asses endoscopic severity
of inflammation and to obtain biopsies to evaluate for
cytomegalovirus(CMV) colitis
• Recommend against routine use of broad spectrum antibiotic and
total parenteral nutrition (TPN)

39. MANAGEMENT OF HOSPITALIZED PATIENT WITH ACUTE SEVERE UC (ASUC)
 Induction of remission:
 A total of 60mg/d of methylprednisolone, hydrocortisone 100 mg 3/4 times daily for
3-5 days
 If fail to adequately respond to IV steroids, recommend rescue therapy with
infliximab or cyclosporine
 Maintenance of remission:
 if achieve emission with Infliximab, recommend maintenance of remission with
same agent, who achieve remission with infliximab treatment
 If achieve remission with cyclosporine treatment, suggest maintenance of
remission with thiopurine or Vedolizumab

40. SURGICAL TREATMENT ( 25% cases )
 Colonic dysplasia or carcinoma
 Chronic refractory UC not responding to traditional medical therapy
 Toxic megacolon, colonic perforation
 Intolerable or unacceptable side effects of medical therapy
 Systemic complications that are recurrent or unmanageable
 Uncontrollable colonic hemorrhage

41. PROCEDURES
 Proctocolectomy with ileal Pouch-Anal Anastomosis(IPAA)
 Currently operation of choice who require elective colectomy
 Total proctocolectomy and end ileostomy
 Total proctocolectomy and continent ileostomy

42.  E. Proctocolectomy with ileal Pouch-Anal
Anastomosis(IPAA)
 C. Total proctocolectomy and end ileostomy
 D. Total proctocolectomy and continent ileostomy