Ulcerative colitis is a relapsing inflammatory bowel disease that affects the colonic mucosa. It can involve regions of the colon from just the rectum to the entire colon. The main symptoms are bloody diarrhea, abdominal discomfort, and urgency. Diagnosis involves blood tests, stool samples, imaging like barium enema or colonoscopy with biopsy. Treatment ranges from medications like 5-aminosalicylates and corticosteroids for mild disease to intravenous corticosteroids, nutrition support, cyclosporine or infliximab for severe disease, with colectomy considered for refractory cases. Surveillance colonoscopy is needed due to increased cancer risk.

1. Ulcerative
colitis (UC)
Domina Petric, MD

2. Introduction
• UC is a relapsing and remitting inflammatory
disorder of the colonic mucosa.
• It may affect just the rectum (proctitis, 50%) or
extend to involve part of the colon (left-sided
colitis, 30%).
• It can involve the entire colon (pancolitis, 20%).
• UC almost never spreads proximal to the
ileocaecal valve, except in the case of
BACKWASH ILEITIS (rare).

3. Pathology
Hyperaemic/haemorrhagic granular
colonic mucosa with or without
pseudopolyps formed by inflammation.
Punctate ulcers may extend deep into the
lamina propria.
Inflammation is normally not transmural.

4. Histology
• inflammatory infiltrate
• goblet cell depletion
• glandular distortion
• mucosal ulcers
• crypt abscesses

5. Wikipedia.org
Medscape.com

6. Epidemiology
• Prevalence is 100-200/100000.
• Incidence is 10-20/100000/year.
• Most present aged 15-30 years.
• It is more prevalent in nonsmokers.
• Symptoms may relapse on
stopping smoking.

7. Symptoms
• Episodic or chronic diarrhoea:
blood, mucus.
• Crampy abdominal discomfort.
• Bowel frequency relates to
severity.
• Urgency/tenesmus, especially in
rectal disease.

8. Systemic symptoms in
attacks are:

9. Signs
• There may be no signs.
• In acute, severe UC there
may be fever, tachycardia
and a tender, distended
abdomen.

10. Extraintestinal signs
• clubbing
• aphthous oral
ulcers
• erythema
nodosum
• pyoderma
gangrenosum
• conjunctivitis
• episcleritis
• iritis
• large joint arthritis
• sacroiliitis
• ankylosing
spondylitis
• fatty liver
Clubbing
(Wikipedia.org)

11. Extraintestinal signs
• primary sclerosing
cholangitis
• cholangiocarcinoma
• nutritional deficits
• amyloidosis

12. Tests
• Blood: full blood count, erythrocyte
sedimentation rate (ESR), CRP,
urea, creatinine, electrolytes, blood
culture, liver function tests.
• Stool microbiology to exclude
Campylobacter, C. difficile,
Salmonella, Shigella, E. coli,
amoebae.

13. Tests
• Abdominal X ray: no faecal
shadows, mucosal thickening or
islands.
• Erect chest X ray: if perforation.
• Barium enema: contraindicated
during severe attacks.
• Colonoscopy: best choice, biopsy.

14. Radiopaedia.com

15. Truelove, Witts criteria
Variable Mild UC Moderate UC Severe UC
Motions/day <4 4-6 >6
Rectal bleeding Small Moderate Large
T0C at 6 AM Apyrexial 37,1-37,80 C >37,80 C
Resting pulse <70 bpm 70-90 bpm >90 bpm
Haemoglobin >110 g/L 105-110 g/L <105 g/L
ESR <30 >30
CRP <16 >45

16. Complications
• perforation
• bleeding
• toxic dilatation of colon (mucosal
islands, colonic diameter >6 cm)
• venous thrombosis
• colonic cancer

17. Complications
• Intra-epithelial neoplasms may occur
in flat, normal-looking mucosa.
• Surveillance colonoscopy is done
every 2-4 years with 4 random
biopsies/10 cm of mucosa.
• Endomicroscopy may increase
detection rates.

18. Therapy for mild UC
• 5-ASA (sulfasalazine,
mesalazine).
• Steroids: prednisolone 20 mg/d
per os may be useful for inducing
remission.
• If the patient is improving, lower
steroids slowly.

19. Therapy for moderate UC
• Oral prednisolone 40 mg/d for 1
week, then 30 mg/d for 1 week,
than 20 mg/d for 4 more weeks
and 5-ASA and twice-daily
steroid enemas.
• If the patient is improving, lower
steroids gradually.

20. Severe UC
• Admit in hospital.
• Nil by mouth.
• Iv. hydration: 1 L of 0,9%
saline + 2 L of dextrose-
saline/24 hours + 20 mmol
K+/L (less if elderly).

21. Severe UC
Hydrocortisone 100 mg/6 hours iv.
Rectal steroids, hydrocortisone 100 mg in
100 mL 0,9% saline/12 hours per rectum.
Monitor temperature, pulse and blood pressure.
Record stool frequency and character.

22. Severe UC
• Daily blood tests.
• Parenteral nutrition is required if
the patient is severely
malnourished.
• After improvement, transfer to
prednisolone per os 40 mg/24 h
with 5-ASA to maintain remission.

23. Severe UC
If there is no improvement:
CICLOSPORIN or
INFLIXIMAB.
Urgent colectomy in refractory
patients with very severe
disease.

24. Indications for surgery
Indications for proctocolectomy and
terminal ileostomy or colectomy with
ileo-anal pouch later are:
• perforation
• massive haemorrhage
• toxic dilatation
• failed medical therapy

25. Immunomodulation
Indications for azathioprine,
methotrexate, infliximab,
adalimumab, ciclosporin or
tacrolimus:
• no remission with steroids
• prolonged use of steroids
required

26. Literature
• Oxford Handbook of Clinical
Medicine. Longmore M. Wilkinson I.
B. Baldwin A. Elizabeth W. Ninth
edition.
• Wikipedia.org
• Medscape.com
• Radiopaedia.com