Ulcerative colitis is a chronic inflammatory bowel disease that affects the colon. The main symptoms include diarrhea mixed with blood, abdominal pain, and weight loss. The inflammation typically involves the rectum and extends proximally in the colon. The disease severity and extent of colon involvement are used to classify patients. Complications can include toxic megacolon, colon cancer, and extraintestinal manifestations affecting other organs.

1. Ulcerative colitisUlcerative colitis (UC) is a chronic disease of unknown(UC) is a chronic disease of unknown
etiology characterized by inflammation of the mucosa andetiology characterized by inflammation of the mucosa and
submucosa of the large intestine.submucosa of the large intestine.
The inflammation usually involves the rectum down to theThe inflammation usually involves the rectum down to the
anal margin and extends proximally in the colon for aanal margin and extends proximally in the colon for a
variable distance.variable distance.
There is no difference between men and women.There is no difference between men and women.
The worldwide incidence is 0.5~24 new cases per 100 000The worldwide incidence is 0.5~24 new cases per 100 000
individuals, and prevalence is 100~200 cases per 100 000.individuals, and prevalence is 100~200 cases per 100 000.
Introduction

2. UC: is a form of (IBD). It is a form of colitis, of that includesUC: is a form of (IBD). It is a form of colitis, of that includes
characteristic ulcers, or open sores, in the colon.characteristic ulcers, or open sores, in the colon.
The main symptom of active disease is usually diarrheaThe main symptom of active disease is usually diarrhea
mixed with blood, of gradual onset.mixed with blood, of gradual onset.
UC is, however, a systemic disease that affects many partsUC is, however, a systemic disease that affects many parts
of the body outside the intestine. Because of the name, IBDof the body outside the intestine. Because of the name, IBD
is often confused with irritable bowel syndrome ("IBS"), ais often confused with irritable bowel syndrome ("IBS"), a
troublesome, but much less serious condition.troublesome, but much less serious condition.

3. External environmentExternal environment
It is indisputable that the emergence of IBD in various partsIt is indisputable that the emergence of IBD in various parts
of the world is associated with social and economicalof the world is associated with social and economical
progress, as initially observed in Northern Europe andprogress, as initially observed in Northern Europe and
North America, then the rest of Europe, South America andNorth America, then the rest of Europe, South America and
Japan, and further the Asian Pacific region, as we are nowJapan, and further the Asian Pacific region, as we are now
witnessing.witnessing.
A large number of unrelated environmental factors areA large number of unrelated environmental factors are
considered risk factors for IBD, includingconsidered risk factors for IBD, including smokingsmoking, diet,, diet,
drugs (oral contraceptive and NSAIDs).drugs (oral contraceptive and NSAIDs).
Current concept of etiopathogenesis

4. GeneticsGenetics
There is an increased familial incidence of IBD, both forThere is an increased familial incidence of IBD, both for
Crohn’s disease and ulcerative colitis.Crohn’s disease and ulcerative colitis.
This is due in large part to technological advances in DNAThis is due in large part to technological advances in DNA
analsis and sequencing, such as genome-wideanalsis and sequencing, such as genome-wide
associational, and the use of huge multicenter orassociational, and the use of huge multicenter or
multinational databases.multinational databases.
The era modern IBD genetics began in 2001 with theThe era modern IBD genetics began in 2001 with the
discovery of mutations in the NOD2/CARD15 gene, the firstdiscovery of mutations in the NOD2/CARD15 gene, the first
susceptibility gene in CD.susceptibility gene in CD.
Polymorphisms of TLR4 have been associated with anPolymorphisms of TLR4 have been associated with an
increased risk for UC as well as CD.increased risk for UC as well as CD.

5. Microbial factorsMicrobial factors
Among the components of IBD pathogenesis, theAmong the components of IBD pathogenesis, the
investigation of role of infectious agents and the gutinvestigation of role of infectious agents and the gut
commensal flora is an area in which relatively lesscommensal flora is an area in which relatively less
progress has occurred.progress has occurred.
There are two main reasons for thisThere are two main reasons for this
(1) Only isolated reports on new infectious agents with an(1) Only isolated reports on new infectious agents with an
etiologic potential for IBD have been published in severaletiologic potential for IBD have been published in several
years, and (2) major methodological difficuties areyears, and (2) major methodological difficuties are
encountered in the study of the flora in the human gut.encountered in the study of the flora in the human gut.

6. Immunological factorsImmunological factors
The investigation of IBD pathogenesis has been dominatedThe investigation of IBD pathogenesis has been dominated
for a long time by studies of mucosal immunity and, infor a long time by studies of mucosal immunity and, in
particular, studies of the function of local T cells in Cd andparticular, studies of the function of local T cells in Cd and
UC tissues.UC tissues.

7. Additional factorsAdditional factors
In addition to the environmental, genes, microbes, and theIn addition to the environmental, genes, microbes, and the
immune system, other factors also participate in IBDimmune system, other factors also participate in IBD
pathogenesis, and two in particular are worth mentioning:pathogenesis, and two in particular are worth mentioning:
FibrosisFibrosis ：：
AngiogenesisAngiogenesis ：： It has recently been shown to be a novelIt has recently been shown to be a novel
and important component of IBD pathogenesis, and oneand important component of IBD pathogenesis, and one
likely to contribute to the chronicity of the disease.likely to contribute to the chronicity of the disease.
Angiogenesis blockage is effective in decreasingAngiogenesis blockage is effective in decreasing
inflammation in experimental colitis.inflammation in experimental colitis.

8. Pathologic changes in the colon in UC readily predict thePathologic changes in the colon in UC readily predict the
clinical features of the disease.clinical features of the disease.
Unlike the segmental lesions of CD, UC involves primarilyUnlike the segmental lesions of CD, UC involves primarily
the mucosa of the colon, the mucosa is inflamedthe mucosa of the colon, the mucosa is inflamed
continuously.continuously.
The involved mucosa is red and granular and bleedsThe involved mucosa is red and granular and bleeds
diffusely. The macroscopic lesions may progress fromdiffusely. The macroscopic lesions may progress from
small, petechial ulcerations to deeper, linear ulcerssmall, petechial ulcerations to deeper, linear ulcers
separated by islands of inflamed but intact mucosa.separated by islands of inflamed but intact mucosa.
In severe cases, large areas of the colon may be denuded.In severe cases, large areas of the colon may be denuded.
Pathology

9. The characteristic pathology is one of chronic inflammationThe characteristic pathology is one of chronic inflammation
characterized by large numbers of lymphocytes andcharacterized by large numbers of lymphocytes and
histocytes in the diseased mucosa and submucosa with anhistocytes in the diseased mucosa and submucosa with an
acute inflammatory infiltrate composed of neutrophilsacute inflammatory infiltrate composed of neutrophils
variably present.variably present.
The alterating processes of superfical ulceration andThe alterating processes of superfical ulceration and
granulation followed by re-epithelialization can lead to thegranulation followed by re-epithelialization can lead to the
development of polypoid excrescences. These aredevelopment of polypoid excrescences. These are
inflammatory polyps(pseudopolyps) that are notinflammatory polyps(pseudopolyps) that are not
neoplastic.neoplastic.

10. UC is a systemic disease that affects many parts of the body.UC is a systemic disease that affects many parts of the body.
Sometimes the extra-intestinal manifestations of the diseaseSometimes the extra-intestinal manifestations of the disease
are the initial signs, such as painful, arthritic knees in aare the initial signs, such as painful, arthritic knees in a
teenager. It is, however, unlikely that the disease will beteenager. It is, however, unlikely that the disease will be
correctly diagnosed until the onset of the intestinalcorrectly diagnosed until the onset of the intestinal
manifestations.manifestations.

11. The five most common symptoms of UC are rectal bleeding,The five most common symptoms of UC are rectal bleeding,
diarrhea, abdominal pain, weight loss, and fever.diarrhea, abdominal pain, weight loss, and fever.
The clinical presentationThe clinical presentation of UC depends on the extent of theof UC depends on the extent of the
disease process. Patients usually present with diarrheadisease process. Patients usually present with diarrhea
mixed with blood and mucus, of gradual onset.mixed with blood and mucus, of gradual onset.
They also may have signs of weight loss, and blood onThey also may have signs of weight loss, and blood on
rectal examination.rectal examination.
The disease is usually accompanied with different degreesThe disease is usually accompanied with different degrees
of abdominal pain, from mild discomfort to severely painfulof abdominal pain, from mild discomfort to severely painful
cramps.cramps.
Clinical manifestations

12. Extent of involvementExtent of involvement
UCUC is normally continuous from the rectum up the colon.is normally continuous from the rectum up the colon.
The disease is classified by the extent of involvement,The disease is classified by the extent of involvement,
depending on how far up the colon the disease extends:depending on how far up the colon the disease extends:
Distal colitis, potentially treatable with enemas:Distal colitis, potentially treatable with enemas:
Proctitis:Proctitis:
Involvement limited to the rectum.Involvement limited to the rectum.
Proctosigmoiditis:Proctosigmoiditis:
Involvement of the rectosigmoid colon, the portion of theInvolvement of the rectosigmoid colon, the portion of the
colon adjacent to the rectum.colon adjacent to the rectum.
Left-sided colitis:Left-sided colitis:
Involvement of the descending colon, which runs alongInvolvement of the descending colon, which runs along
the patient's left side, up to the splenic flexure and thethe patient's left side, up to the splenic flexure and the
beginning of the transverse colon.beginning of the transverse colon.

13. Extensive colitisExtensive colitis, inflammation extending beyond the reach of, inflammation extending beyond the reach of
enemas:enemas:
Pancolitis:Pancolitis: Involvement of the entire colon, extending fromInvolvement of the entire colon, extending from
the rectum to the cecum, beyond which the small intestinethe rectum to the cecum, beyond which the small intestine
begins.begins.

14. Severity of diseaseSeverity of disease
In addition to the extent of involvement, UC patients may alsoIn addition to the extent of involvement, UC patients may also
be characterized by the severity of their disease.be characterized by the severity of their disease.
Mild diseaseMild disease correlates with fewer than four stools daily, withcorrelates with fewer than four stools daily, with
or without blood, no systemic signs of toxicity, and a normalor without blood, no systemic signs of toxicity, and a normal
erythrocyte sedimentation rate (ESR). There may be milderythrocyte sedimentation rate (ESR). There may be mild
abdominal pain or cramping. Patients may believe they areabdominal pain or cramping. Patients may believe they are
constipated when in fact they are experiencing tenesmus,constipated when in fact they are experiencing tenesmus,
which is a constant feeling of the need to empty the bowelwhich is a constant feeling of the need to empty the bowel
accompanied by involuntary straining efforts, pain, andaccompanied by involuntary straining efforts, pain, and
cramping with little or no fecal output. Rectal pain iscramping with little or no fecal output. Rectal pain is
uncommon.uncommon.

15. Moderate diseaseModerate disease correlates with more than four stools daily,correlates with more than four stools daily,
but with minimal signs of toxicity. Patients may displaybut with minimal signs of toxicity. Patients may display
anemia (not requiring transfusions), moderate abdominalanemia (not requiring transfusions), moderate abdominal
pain, and low grade fever, 38 to 39 °Cpain, and low grade fever, 38 to 39 °C
Severe disease,Severe disease, correlates with more than six bloody stools acorrelates with more than six bloody stools a
day, and evidence of toxicity as demonstrated by fever,day, and evidence of toxicity as demonstrated by fever,
tachycardia, anemia or an elevated ESR.tachycardia, anemia or an elevated ESR.

16. FulminantFulminant disease correlates with more than ten boweldisease correlates with more than ten bowel
movements daily, continuous bleeding, toxicity, abdominalmovements daily, continuous bleeding, toxicity, abdominal
tenderness and distension, blood transfusion requirementtenderness and distension, blood transfusion requirement
and colonic dilation. Patients in this category may haveand colonic dilation. Patients in this category may have
severe inflammation extending beyond just the mucosalsevere inflammation extending beyond just the mucosal
layer, causing impaired colonic motility and leading to toxiclayer, causing impaired colonic motility and leading to toxic
megacolon.megacolon. If the serous membrane is involved, colonicIf the serous membrane is involved, colonic
perforation may ensue. Unless treated, fulminant disease willperforation may ensue. Unless treated, fulminant disease will
soon lead to death.soon lead to death.

17. Extraintestinal featuresExtraintestinal features
As UC is a systemic disease, patients may present withAs UC is a systemic disease, patients may present with
symptoms and complications outside the colon. Thesesymptoms and complications outside the colon. These
include the following:include the following:
 aphthousaphthous ulcers of the mouth .ulcers of the mouth .
 Ophthalmic .Ophthalmic .
 Iritis or uveit.Iritis or uveit.
 Episcleritis.Episcleritis.

18. Patients with ulcerative colitis can occasionally havePatients with ulcerative colitis can occasionally have
aphthous ulcers involving the tongue, lips, palate andaphthous ulcers involving the tongue, lips, palate and
pharynxpharynx

19. Deep venous thrombosisDeep venous thrombosis and pulmonary embolismand pulmonary embolism
Autoimmune hemolytic anemiaAutoimmune hemolytic anemia
clubbingclubbing,,
Primary sclerosingPrimary sclerosing cholangitis, or inflammation of thecholangitis, or inflammation of the
bile ductsbile ducts

20. CLINICAL FEATURESCLINICAL FEATURES
 Clinical typesClinical types
☆☆ Initial attackInitial attack
☆☆ Chronic relapseChronic relapse
☆☆ Chronic continuanceChronic continuance
☆☆ Acute fulminateAcute fulminate
 The degree of severityThe degree of severity
☆☆ MildMild
☆☆ ModerateModerate
☆☆ SevereSevere

21. COMLICATIONCOMLICATION
 Toxic megacolonToxic megacolon
 Carcinoma of the rectum and colonCarcinoma of the rectum and colon
 Others: massive bleeding,Others: massive bleeding,
perforation,perforation,
stricturestricture

23. COMPLICATIONCOMPLICATION

24. Course and complicationsCourse and complications
Progression or remissionProgression or remission
Patients with UC usually have an intermittent course, withPatients with UC usually have an intermittent course, with
periods of disease inactivity alternating with "flares" ofperiods of disease inactivity alternating with "flares" of
disease. Patients with proctitis or left-sided colitis usuallydisease. Patients with proctitis or left-sided colitis usually
have a more benign course: only 15% progress proximallyhave a more benign course: only 15% progress proximally
with their disease, and up to 20% can have sustainedwith their disease, and up to 20% can have sustained
remission in the absence of any therapy. Patients withremission in the absence of any therapy. Patients with
more extensive disease are less likely to sustain remission,more extensive disease are less likely to sustain remission,
but the rate of remission is independent of the severity ofbut the rate of remission is independent of the severity of
diseasedisease

25. UC and colorectal cancerUC and colorectal cancer
There is a significantly increased risk of colorectal cancerThere is a significantly increased risk of colorectal cancer
in patients with UC after 10 years if involvement is beyondin patients with UC after 10 years if involvement is beyond
the splenicflexure. Those with only proctitis orthe splenicflexure. Those with only proctitis or
rectosigmoiditis usually have no increased risk.rectosigmoiditis usually have no increased risk.
It is recommended that patients have screeningIt is recommended that patients have screening
colonoscopies with random biopsies to look for dysplasiacolonoscopies with random biopsies to look for dysplasia
after eight years of diseaseafter eight years of disease

26. LABORATORY FINDINGSLABORATORY FINDINGS
 Blood: anemia, leukocytosis,Blood: anemia, leukocytosis,
ESRESR ↑↑,,
CRPCRP ↑↑,,
hypoalbuminemiahypoalbuminemia
 Stool: no identifiable pathogenic bacteria,Stool: no identifiable pathogenic bacteria,
no parasitesno parasites
 Antibodis: p-ANCA, ASCAAntibodis: p-ANCA, ASCA

27. LABORATORY FINDINGSLABORATORY FINDINGS
 ColonscopyColonscopy
☆☆ Loss of the fine vascular patternLoss of the fine vascular pattern
☆☆ AA geanular appearancegeanular appearance
☆☆ Superfical ulcerationsSuperfical ulcerations
☆☆ MucopusMucopus
☆☆ Postinflammatory polypsPostinflammatory polyps

28. EndoscopicEndoscopic
 The best test for diagnosis of UC remains endoscopy.The best test for diagnosis of UC remains endoscopy.
Full colonoscopy to the cecum and entry into the terminalFull colonoscopy to the cecum and entry into the terminal
ileum is attempted only if diagnosis of UC is unclear.ileum is attempted only if diagnosis of UC is unclear.
 Otherwise, a flexible sigmoidoscopy is sufficient toOtherwise, a flexible sigmoidoscopy is sufficient to
support the diagnosis. The physician may elect to limitsupport the diagnosis. The physician may elect to limit
the extent of the exam if severe colitis is encountered tothe extent of the exam if severe colitis is encountered to
minimize the risk of perforation of the colon. Endoscopicminimize the risk of perforation of the colon. Endoscopic
findings in UC include the following:findings in UC include the following:
Loss of the vascular appearance of the colon, ErythemaLoss of the vascular appearance of the colon, Erythema
(or redness of the mucosa) and friability of the mucosa(or redness of the mucosa) and friability of the mucosa
Superficial ulceration, which may be confluent, andSuperficial ulceration, which may be confluent, and
Pseudopolyps.Pseudopolyps.

29. EndoscopicEndoscopic
UC is usually continuous from the rectum, with theUC is usually continuous from the rectum, with the
rectum almost universally being involved. There is rarelyrectum almost universally being involved. There is rarely
peri-anal disease, but cases have been reported. Theperi-anal disease, but cases have been reported. The
degree of involvement endoscopically ranges fromdegree of involvement endoscopically ranges from
proctitis or inflammation of the rectum, to left sidedproctitis or inflammation of the rectum, to left sided
colitis, to pancolitis, which is inflammation involving thecolitis, to pancolitis, which is inflammation involving the
ascending colonascending colon

34. Polyps In Colitis

35. PseudopolypsPseudopolyps

36. Endoscopic image of ulcerative colitis affecting the left sideEndoscopic image of ulcerative colitis affecting the left side
of the colon. The image shows confluent superficialof the colon. The image shows confluent superficial
ulceration and loss of mucosal architecture. Crohn's diseaseulceration and loss of mucosal architecture. Crohn's disease
may be similar in appearance, a fact that can makemay be similar in appearance, a fact that can make
diagnosing UC a challenge.diagnosing UC a challenge.

37. Colonic pseudopolyps of a patient with intractable
ulcerative colitis. Colectomy specimen.

38. HistologicHistologic
Biopsies of the mucosa are taken to definitively diagnoseBiopsies of the mucosa are taken to definitively diagnose
UC and differentiate it from Crohn's diseas, MicrobiologicalUC and differentiate it from Crohn's diseas, Microbiological
samples are typically taken at the time of endoscopy.samples are typically taken at the time of endoscopy.
The pathology in UC typically involves distortion of cryptThe pathology in UC typically involves distortion of crypt
architecture, inflammation of crypts (cryptitis), frank cryptarchitecture, inflammation of crypts (cryptitis), frank crypt
abscesses, and hemorrhage or inflammatory cells in theabscesses, and hemorrhage or inflammatory cells in the
lamina propria. In cases where the clinical picture islamina propria. In cases where the clinical picture is
unclear, the histomorphologic analysis often plays aunclear, the histomorphologic analysis often plays a
pivotal role in determining the management.pivotal role in determining the management.

40. Diagnosis
The diagnosis of UC is usually made on the basis of its
clinical features, the demonstration of inflammation of the
rectal and sigmoidal mucosa on proctosigmoidosocpy,
and the exclusion of specific infectious by appropriate
stool culture and examination for parasites.
The diagnosis may be supported by radiologic
examination, colooscopy, and rectal biopsy.

41. Differential diagnosisDifferential diagnosis
The following conditions may present in a similar manner andThe following conditions may present in a similar manner and
should be excluded:should be excluded:
Crohn's diseaseCrohn's disease
Infectious colitisInfectious colitis, which is typically detected on stool cultures, which is typically detected on stool cultures
Pseudom embranousPseudom embranous colitis, or Clostridium difficile-colitis, or Clostridium difficile-
associated colitis, bacterial upsets often seen followingassociated colitis, bacterial upsets often seen following
administration of antibioticsadministration of antibiotics
Ischemic colitisIschemic colitis, inadequate blood supply to the intestine,, inadequate blood supply to the intestine,
which typically affects the elderlywhich typically affects the elderly
 Radiation colitisRadiation colitis in patients with previous pelvicin patients with previous pelvic
radiotherapyradiotherapy
Chemical colitisChemical colitis resulting from introduction of harshresulting from introduction of harsh
chemicals into the colon from an enema or other procedure.chemicals into the colon from an enema or other procedure.

42. Standard treatment for UC depends onStandard treatment for UC depends on extentextent of involvementof involvement
and diseaseand disease severityseverity..
The goal is to induce remission initially with medications,The goal is to induce remission initially with medications,
followed by the administration of maintenance medicationsfollowed by the administration of maintenance medications
to prevent a relapse of the disease.to prevent a relapse of the disease.
The concept of induction of remission and maintenance ofThe concept of induction of remission and maintenance of
remission is very important.remission is very important.
Treatment

43. The medications used to induce and maintain a remissionThe medications used to induce and maintain a remission
somewhat overlap, but the treatments are different.somewhat overlap, but the treatments are different.
Physicians first direct treatment to inducing a remissionPhysicians first direct treatment to inducing a remission
which involves relief of symptoms and mucosal healing ofwhich involves relief of symptoms and mucosal healing of
the lining of the colon and then longer term treatment tothe lining of the colon and then longer term treatment to
maintain the remission.maintain the remission.
Current treatments have been effective for many patientsCurrent treatments have been effective for many patients
with UC but have numerous limitations for patients withwith UC but have numerous limitations for patients with
moderate to severe disease.moderate to severe disease.

44. Drugs usedDrugs used
AminosalicylatesAminosalicylates
are the mainstay of UC pharmacotherapy for induction andare the mainstay of UC pharmacotherapy for induction and
maintenance of remission for patients with mild tomaintenance of remission for patients with mild to
moderate disease.moderate disease.
SulfasalazineSulfasalazine
MesalazineMesalazine,,
SulfasalazineSulfasalazine,,
BalsalazideBalsalazide --
OlsalazineOlsalazine,,

45. CorticosteroidsCorticosteroids
It is often required for the one-third of patients who fail toIt is often required for the one-third of patients who fail to
respond to 5-ASAs, But it is not useful for maintenancerespond to 5-ASAs, But it is not useful for maintenance
of remission and carry significant undesirable sideof remission and carry significant undesirable side
effects, as osteoporosis, glucose intolerance, andeffects, as osteoporosis, glucose intolerance, and
increased risk of infection.increased risk of infection.

46. Immunosupressive drugsImmunosupressive drugs
It have a role in maintenance of remission in moderate toIt have a role in maintenance of remission in moderate to
severe UC. Their relatively slow onset of action precludessevere UC. Their relatively slow onset of action precludes
their use during flares of the disease, and the use of thesetheir use during flares of the disease, and the use of these
agents has been reported to potentially increase the risk ofagents has been reported to potentially increase the risk of
lymphoma in patients with IBD. It requires intenselymphoma in patients with IBD. It requires intense
monitoring, and may cause irreversible nephrotoxicity, allmonitoring, and may cause irreversible nephrotoxicity, all
of which limit its use to severe cases only.of which limit its use to severe cases only.

47.  Mercaptopurine, also known as 6-Mercaptopurine, 6-MPMercaptopurine, also known as 6-Mercaptopurine, 6-MP
and Purinethol.and Purinethol.
 Azathioprine, also known as Imuran, Azasan or Azamun,Azathioprine, also known as Imuran, Azasan or Azamun,
which metabolises to 6-MP.which metabolises to 6-MP.
 Methotrexate.Methotrexate.
 Tacrolimus.Tacrolimus.

48. Biological treatmentBiological treatment
It refers to the use of medication that is tailored toIt refers to the use of medication that is tailored to
specifically target an immune or genetic mediator ofspecifically target an immune or genetic mediator of
disease. The, molecules that are involved in the diseasedisease. The, molecules that are involved in the disease
process have been identified, and can be targeted forprocess have been identified, and can be targeted for
biological therapy; many of these molecules, which arebiological therapy; many of these molecules, which are
mainly cytokines, are directly involved in the immunemainly cytokines, are directly involved in the immune
system.system.
Biological therapy has found a niche in the management ofBiological therapy has found a niche in the management of
cancer, autoimmune diseases, and diseases of unknowncancer, autoimmune diseases, and diseases of unknown
cause that result in symptoms due to immune relatedcause that result in symptoms due to immune related
mechanisms .mechanisms .
(Infliximab ,Visilizumab)(Infliximab ,Visilizumab)

49. InfliximabInfliximab is known as a "chimeric monoclonal antibody"is known as a "chimeric monoclonal antibody"
(the term "chimeric" refers to the use of both mouse(the term "chimeric" refers to the use of both mouse
(murine) and human components of the drug.(murine) and human components of the drug.
The drug blocks the action of TNFα (tumor necrosis factorThe drug blocks the action of TNFα (tumor necrosis factor
alpha) by binding to it and preventing it from signaling thealpha) by binding to it and preventing it from signaling the
receptors for TNFα on the surface of cells. TNFα is one ofreceptors for TNFα on the surface of cells. TNFα is one of
the key cytokines that triggers and sustains thethe key cytokines that triggers and sustains the
inflammation respone.inflammation respone.

50. VisilizumabVisilizumab is a humanized monoclonal antibody. It isis a humanized monoclonal antibody. It is
being investigated for use as an immunosuppressive drugbeing investigated for use as an immunosuppressive drug
in patients with UC and Crohn's disease. Visilizumab bindsin patients with UC and Crohn's disease. Visilizumab binds
to the CD3 receptor on certain activated T cells withoutto the CD3 receptor on certain activated T cells without
effecting resting T cells. It is currently under clinicaleffecting resting T cells. It is currently under clinical
studies.studies.

51. SurgerySurgery
Failure of medical therapy leads to colectomy in (9% - 35%) ofFailure of medical therapy leads to colectomy in (9% - 35%) of
patients with UC within 5 years. Colectomy is considered topatients with UC within 5 years. Colectomy is considered to
be an important adjunct treatment for refractory UC;be an important adjunct treatment for refractory UC;
however, colectomy with ileal pouch anal anastomosis (thehowever, colectomy with ileal pouch anal anastomosis (the
standard surgical therapy) has many limitations and isstandard surgical therapy) has many limitations and is
associated with its own set of complications, including highassociated with its own set of complications, including high
stool frequency, female infertility, and a cumulative incidencestool frequency, female infertility, and a cumulative incidence
of chronic pouchitis of 50% at 10 years.of chronic pouchitis of 50% at 10 years.

52. SurgerySurgery
Absolute indications for subtotal or total colectomy are:Absolute indications for subtotal or total colectomy are:
(1)(1) perforation, with or without abscess formationperforation, with or without abscess formation
(2)(2) colonic carcinoma, for which total protocolectomy and lymphcolonic carcinoma, for which total protocolectomy and lymph
node dissection are requirednode dissection are required
(3)(3) massive hemorrhagemassive hemorrhage
Relative indications are as follow:Relative indications are as follow:
(1)(1) Severe acute colitis with or without toxic dilatation of the colon,Severe acute colitis with or without toxic dilatation of the colon,
with failure to respond to maximal therapywith failure to respond to maximal therapy
(2)(2) Failure to medical managementFailure to medical management
(3)(3) Suspicion of cancerSuspicion of cancer

53. Unlike Crohn's disease, UC can generally be cured byUnlike Crohn's disease, UC can generally be cured by
surgical removal of the large intestine. This procedure issurgical removal of the large intestine. This procedure is
necessary in the event of: exsanguinating hemorrhage, franknecessary in the event of: exsanguinating hemorrhage, frank
perforation or documented or strongly suspected carcinoma.perforation or documented or strongly suspected carcinoma.
Surgery is also indicated for patients with severe colitis orSurgery is also indicated for patients with severe colitis or
toxic megacolon.toxic megacolon.
Patients with symptoms that are disabling and do notPatients with symptoms that are disabling and do not
respond to drugs may wish to consider whether surgeryrespond to drugs may wish to consider whether surgery
would improve the quality of life.would improve the quality of life.
In rare cases the extra-intestinal manifestations of theIn rare cases the extra-intestinal manifestations of the
disease may require removal of the colon.disease may require removal of the colon.

54. Alternative treatmentsAlternative treatments
Smoking :Smoking :
Unlike Crohn's disease, UC has a lesser prevalence inUnlike Crohn's disease, UC has a lesser prevalence in
smokers than non-smokers .smokers than non-smokers .
Dietary modification :Dietary modification :
Dietary modification may reduce the symptoms of theDietary modification may reduce the symptoms of the
disease.disease.
Lactose intolerance is noted in many ulcerative colitisLactose intolerance is noted in many ulcerative colitis
patients. Those with suspicious symptoms should get apatients. Those with suspicious symptoms should get a
lactose breath hydrogen test.lactose breath hydrogen test.

55. Patients with abdominal cramping or diarrhea may find reliefPatients with abdominal cramping or diarrhea may find relief
or a reduction in symptoms by avoiding fresh fruits andor a reduction in symptoms by avoiding fresh fruits and
vegetables, caffeine, carbonated drinks and sorbitol-vegetables, caffeine, carbonated drinks and sorbitol-
containing foods.containing foods.
Many dietary approaches have purported to treat UC,Many dietary approaches have purported to treat UC,
including the ElaineGottschall's specific carbohydrate dietincluding the ElaineGottschall's specific carbohydrate diet
and the "anti-fungal diet" (Holland/Kaufmann).and the "anti-fungal diet" (Holland/Kaufmann).
The use of elemental and semi-elemental formula has beenThe use of elemental and semi-elemental formula has been
successful in pediatric patientssuccessful in pediatric patients

56. Intestinal parasitesIntestinal parasites
IBD is less common in the developing world. Some haveIBD is less common in the developing world. Some have
suggested that this may be because intestinal parasites aresuggested that this may be because intestinal parasites are
more common in underdeveloped countries. Some parasitesmore common in underdeveloped countries. Some parasites
are able to reduce the immune response of the intestine, anare able to reduce the immune response of the intestine, an
adaptation that helps the parasite colonize the intestine. Theadaptation that helps the parasite colonize the intestine. The
decrease in immune response could reduce or eliminate thedecrease in immune response could reduce or eliminate the
IBD.IBD.

57. PrognosisPrognosis
The outlook for recovery from a first attack of UC is veryThe outlook for recovery from a first attack of UC is very
good.good.
Mortality, which is about 5%, occurs almost exclusively inMortality, which is about 5%, occurs almost exclusively in
those who have a severe form of the disease involving thethose who have a severe form of the disease involving the
entire colon.entire colon.
The mortality is higher in patients over 60 years,
approximately 17%, compared to 2% in patients between
ages 20 and 59.
Toxic megacolon has a mortality rate of about 20 percent.
Death generally results from the complications of massive
hemorrhage, systemic infections, pulmonary embolism, or
associated cardiac disorders.