BACKGROUND

Figure 1: Major Type of IBD(Kumar, et al., 2007)

BACKGROUND

Ulcerative Colitis:

was first described in the mid-1800s

incidence is 1.2-20.3 per 100.000 person/year >> than

CD

most common form of IBD in adults

linked to smoking, diets high in fat and sugar,

medication, stress, and high socioeconomic status

incidence is in Europe and America and lowest in Asia

frequency in developed countries has been increasing

Only few articles discuss about UC

OBJECTIVE

To review the current understanding of the

pathophysiology, diagnosis, and treatment of

ulcerative colitis to date

PATHOGENESIS

Genetic factors

Microbiologic

factors

Mucosal immune

response

Epithelial

dysfunction and

autoimmunity

CLINICAL FEATURES

Mucosal inflammation, commencing in the rectum

(proctitis) and spreading proximally to the colon

Bloody diarrhea with or without mucus

Gradual onset, often followed by periods of

spontaneous remission and subsequent relapses

(chronic-exacerbation-remission)

Fecal urgency, tenesmus, constipation, abdominal

pain, fever, malaise, weight loss may occur

EXTRAINTESTINAL MANIFESTATION

COMPLICATION

DIAGNOSTIC

Endoscopic*

Biopsy*

ultrasonographic

radiologic

ENDOSCOPIC

Colonoscopy

Uniformly inflamed mucosa that starts at the

anorectal verge and extends proximally with an

abrupt or a gradual transition from affected to

normal mucosa

Mild Ulcerative Colitis (UC)

Mucosa has a granular

Erythematous appearance

Friability

Loss of the vascular pattern

Moderate UC :Erosions or microulcerations

Severe UC : shallow ulcerations with spontaneous

bleeding

Differentiate UC from CD : Rectal sparing, aphthous

ulcers, skip lesions, a cobblestone pattern, longitudinal

and irregular ulcers

ENDOSCOPIC

HISTOLOGIC EVALUATION

Inflammation restricted to the mucosal layer

Infiltrates consist primarily of lymphocytes, plasma

cells, granulocytes

Goblet cell depletion

Distorted crypt architecture

Epitheloid granuloma are not present : typical of CD

Epithelial dysplasia

No exact criteria for diagnosis of UC : but the

presence of 2 or 3 histologic feature above will suffice

LABORATORY TEST

Helpful in assessing and monitoring disease activity

and differentiating UC from other form of colitis

CBC

Fecal lactoferrin or calprotectin ->severity

Stool cultures for Clostridium difficile,

campylobacter species, Escherichia coli

Histologic, immunochemical, serologic, culture,

DNA testing -> rule out CMV infection

ASCA and pANCA (differentiate UC, CD, IC)

MEDICAL THERAPY

Level of clinical activity

Mild, moderate, or severe

Extent of disease

Proctitis, left-sided disease, extensive disease, or

pancolitis

Course of disease during FU

Patients preferences

PROCTITIS

• Mild to moderate: given for 2 weeks and can be

repeated : Mesalamine supp 1 g/d or enema 2-4 g/d

• If fails : hydrocortisone 100mg/d are a next step

No response to rectally : oral glucocorticoids

(Prednisone up to 40 mg/d)

LEFT SIDED COLITIS TO EXTENSIVE UC

Combination of oral and rectal 5-aminosalicylate up to

4,8 g/d

A once daily dose of 5-aminosalycilate :2 g/d

Oral glucocorticoid or immunosuppressive agents

(azathioprine or 6-mercaptopurine)

I.V glucocorticoid : 5-7 days

Monoclonal antibody against TNF-alfa: infliximab

5mg/kg of body weight at 0,2, and 6 weeks

MAINTENANCE OF REMMISION

Oral and rectal 5-aminosalicylate

Azathioprine 2,5mg/kg body weight 6-mercaptopurine 1,5 mg/kg body weight

Anti TNF-alfa : infliximab

Respond to probiotic therapy : VSL#3

SURGICAL TREATMENT

Reported Colectomy : <5% - >20% patients with UC

Surgery can be curative

Indication for surgery : Failure of medical therapy

Intractable fulminant colitis

Toxic megacolon

Perforation

Uncontrollable bleeding

Intolerable side effects of medications

Stricture

Uresectable high grade or multifocal dysplasia

Dysplasia-associated lession or masses

Cancer

Growth retardation in children

SURGICAL TREATMENT

Possible complication of surgery:

Small-bowel obstruction

Fistulas

Persistent pain

Sexual and bladder dysfunction

infertility

Total proctolectomy with ileal pouch-anal

anastomosis (IPAA) *

Complication : pouchitis (40%)

Symptoms : increased stool frequency, urgency,

incontinence, seepage, abdominal and perianal discomfort

FUTURE IMPLICATIONS

Figure 2. Agents for Which Evidence of Therapeutic Eff icacy in Ulcerative Colitis is Established or Preliminary

THANK YOU