Ulcerative colitis is a type of inflammatory bowel disease that affects the large intestine. It is characterized by inflammation and ulcers in the lining of the colon. The main symptoms include rectal bleeding, frequent diarrhea, and abdominal pain. Diagnosis involves blood tests, colonoscopy, and ruling out other conditions. Treatment focuses on inducing and maintaining remission through medications like mesalamine, corticosteroids, immunosuppressants, and biologics. Surgery may be needed for severe cases or complications that do not respond to medical management. The goals of treatment are to achieve mucosal healing and prevent hospitalizations and surgery.

1. ULCERTATIVE
COLITIS
By dr javeria

2. DEFINITION
• Ulcerative colitis (UC) is one of the two major
types of inflammatory bowel disease (IBD), along
with Crohn disease (CD). ulcerative colitis
characteristically involves the large bowel
.Ulcerative colitis is a lifelong illness that has a
profound emotional and social impact on the
affected patients.
• 80% patients have disease extending from the
rectum to the splenic flexure,
• 20% have pancolitis.

3. SIGNS AND SYMPTOMS
• Rectal bleeding
• Frequent stools
• Mucous discharge
from the rectum
• Tenesmus
(occasionally)
• Lower abdominal pain
and severe
dehydration from
purulent rectal
discharge (in severe
cases, especially in the
elderly)

4. FULMINANT COURSE
• Severe diarrhea and
cramps
• Fever
• Leukocytosis
• Abdominal distention

5. EXTRACOLONIC
MANIFESTATIONS
• Uveitis
• Pyoderma gangrenosum
• Pleuritis
• Erythema nodosum
• Ankylosing spondylitis
• Spondyloarthropathies
• Primary sclerosing
cholangitis (PSC)
• Recurrent subcutaneous
abscesses unrelated to
pyoderma gangrenosum
• Multiple sclerosis
• Immunobullous disease of
the skin

6. DIAGNOSIS
• Serologic markers (e.g. anti neutrophil cytoplasmic antibodies
[ANCA], anti– saccharomyces cerevisiae antibodies [ASCA])
• Complete blood cell (CBC) count
• Comprehensive metabolic panel
• Inflammation markers (e.g. erythrocyte sedimentation rate [ESR], c-
reactive protein [CRP])
• Stool assays
• Colonoscopy and bx

7. IMAGING MODALITIES
• Plain abdominal radiography
• Double-contrast barium enema examination
• Cross-sectional imaging studies (e.g. ultrasonography,
magnetic resonance imaging, computed tomography
scanning)
• Radionuclide studies
• Angiography

8. MONTREAL CLASSIFIACTION
• The severity of UC can be graded as follows:
• Mild: Bleeding per rectum, fewer than four bowel motions per
day
• Moderate: Bleeding per rectum, more than four bowel
motions per day
• Severe: Bleeding per rectum, more than four bowel motions
per day, and a systemic illness with hypoalbuminemia (< 30
g/L)

10. PARIS CLASSIFICATION
• The extent of disease is defined by the following findings on
endoscopy:
• Extensive disease: Evidence of UC proximal to the splenic
flexure
• Left-side disease: UC present in the descending colon up to,
but not proximal to, the splenic flexure
• Proctosigmoiditis: Disease limited to the rectum with or
without sigmoid involvement

13. ENDOSCOPIC FINDINGS:
• Abnormal erythematous
mucosa, with or without
ulceration, extending
from the rectum to a
part or all of the colon
• Uniform inflammation,
without intervening
areas of normal mucosa
• Contact bleeding may
also be observed, with
mucus identified in the
lumen of the bowel

14. • Characteristic
Endoscopic findings
of ulcerative colitis :
• Loss of vascular
pattern
• Granular and fragile
mucosa
• Ulceration, erosions,
and/or
pseudopolyposis

15. Histologic Findings
• (UC) is limited to the mucosa and sub mucosa.
• In fulminant cases, the muscularis propria can be affected.
• Pathologic features are intense infiltration of the mucosa and
sub mucosa with neutrophils and crypt abscesses, lamina
propria with lymphoid aggregates, plasma cells, and mast cells
and eosinophil's, as well as shortening and branching of the
crypts.
• Goblet cell depletion is also notable.

17. MANAGEMENT
• Mild disease confined to the rectum: Topical mesalazine via
suppository (preferred) or budesonide rectal foam
• Left-side colonic disease: Mesalazine suppository and oral
aminosalicylate (oral mesalazine is preferred to oral sulfasalazine)
• Systemic steroids, when disease does not quickly respond to amino
salicylates
• Oral budesonide
• After remission, long-term maintenance therapy (e.g. once-daily
mesalazine)

18. • Medical treatment of acute, severe UC may include the
following:
• Hospitalization
• Intravenous high-dose corticosteroids
• Alternative induction medications: Cyclosporine, tacrolimus,
infliximab, adalimumab, golimumab

19. INDICATIONS FOR URGENT
SURGERY
• Toxic mega colon refractory to medical management
• Fulminant attack refractory to medical management
• Uncontrolled colonic bleeding

20. INDICATIONS FOR ELECTIVE
SURGERY
• Long-term steroid dependence
• Dysplasia or adenocarcinoma found on screening biopsy
• Disease being present for 7-10 years

21. SURGICAL OPTIONS
• Total colectomy (panproctocolectomy) and ileostomy
• Total colectomy
• Ileoanal pouch reconstruction or ileorectal anastomosis
• In an emergency, subtotal colectomy with end-ileostomy

22. American College of Gastroenterology
Guideline
• Stool testing is recommended to exclude Clostridioides
difficile when UC is suspected.
• Serologic antibody testing is not recommended for the following:
• To establish or exclude a diagnosis of UC
• To determine the prognosis of UC

23. GOALS FOR MANAGING PATIENTS
WITH UC
• Treat patients with UC to achieve
• mucosal healing (i.e. resolution of inflammatory changes
• [Mayo endoscopic sub score 0 or 1]) to increase the likelihood of
sustained steroid-free remission
• prevent hospitalizations and surgery.

24. UC management
• Induction and maintenance of remission in mildly active UC
• Patients with, or who previously had, mildly active ulcerative
proctitis are recommended to receive rectal (PR) 5-
aminosalicylate (5-ASA) therapies at a dose of 1 g/d to induce
or maintain remission.
• To induce remission in patients with mildly active left-sided
UC:
• Rectal 5-ASA enemas at a dose of at least 1 g/d are preferred
over rectal steroids.
• In the setting of intolerance or nonresponse to oral (PO) and
PR 5-ASA at appropriate doses (PO: ≥2 g/d; PR: ≥1 g/d), use
PO budesonide multi-matrix (MMX) 9 mg/d.

25. • Patients with UC of any extent whose condition fails to respond to
5-ASA therapy are recommended to receive PO systemic
corticosteroids to induce remission.
• Patients with mildly to moderately active UC refractory to PO 5-ASA
are recommended to additionally receive budesonide MMX 9 mg/d
to induce remission.
• Patients with mildly to moderately active UC of any extent using 5-
ASA to induce remission are recommend to receive either once-
daily or more frequently dosed PO 5-ASA based on patient
preference to optimize adherence, as efficacy and safety are no
different.
• Patients with mildly active left-sided or extensive UC are
recommend to receive at least 2 g/d of PO 5-ASA therapy for
maintenance of remission.
• Systemic corticosteroids are not recommended to maintain
remission in patients with UC.

26. Managementofmoderately to severely activeUC
• Induction of remission
• For moderately active UC, PO budesonide MMX is recommended to
induce remission.
• For moderately to severely active UC of any extent, PO systemic
corticosteroids are recommended to induce remission.
• To induce remission in patients with moderately to severely active UC,
note the following:
• Monotherapy with thiopurines or methotrexate is not recommended.
• Anti-tumor necrosis factor (TNF) therapy using adalimumab, golimumab,
or infliximab is recommended.
• When infliximab is used as induction therapy, combination therapy with a
thiopurine is recommended.
• Vedolizumab or tofacitinib (tofacitinib: 10 mg PO twice daily × 8 wk) is
recommended (either agent is also recommended when anti-TNF therapy
has failed previously).

27. Maintenance of remission in those with
previouslymoderately to severely active UC
• Systemic corticosteroids are not recommended to maintain
remission in patients with UC.
• Continue anti-TNF therapy using adalimumab, golimumab, or
infliximab to maintain remission after anti-TNF induction in
patients with previously moderately to severely active UC.
• Continue vedolizumab to maintain remission in patients with
previously moderately to severely active UC now in remission
after vedolizumab induction.
• Continue tofacitinib to maintain remission in patients with
previously moderately to severely active UC now in remission
after tofacitinib induction.

28. Management of hospitalized
patients with acute severe UC
(ASUC)
• Apply deep venous thrombosis (DVT) prophylaxis to prevent venous
thromboembolism (VTE).
• Test for C difficile infection (CDI).
• In the setting of ASUC and concomitant CDI, treat CDI with
vancomycin instead of metronidazole.
• Routine use of broad-spectrum antibiotics is not recommended to
manage ASUC.
• Use methylprednisolone 60 mg/d or hydrocortisone 100 mg 3 or 4
times daily to induce remission.
• In the setting of ASUC with inadequate response to intravenous
corticosteroids (IVCS) by 3-5 days, medical rescue therapy with
infliximab or cyclosporine is recommended.
• When remission is achieved with infliximab treatment, maintain
remission with infliximab