ULCERATIVE COLITISBy Dr. Ye Htet Aung

• UC is a disease of the rectum and colon with Extra-intestinal manifestations.

Aetiology

Causes - ????

UNKNOWN

• There is clearly a Genetic Contribution

–10-20% of patients have first degree relatives of IBD

• UC–More common in Caucasians than Asians

and AfroCaribbeans

–No causative link with any specific organisms

–Others • Smoking seems to have protective effects

• Patients’ comments – relapses are associated with stress at home or at work

• But personality and psychiatric profiles are the same as those of normal porpulation.

Pathology

• Virtually all cases,–Disease starts in the Rectum and– Extends proximally.

• Rectal sparing–Only in those using topical rectal

preparations

• Colonic inflammation

–Diffuse, confluent and superficial

–Affecting mucosa and submucosa

– Severe cases – affecting full thickness of the colon

• Chronic mucosal ulceration

– Formation and regeneration of granulation tissue leading to a polyp-like appearance

–Pseudo-polyps

• Stricture – unusual in UC

• Histology

– Inflammatory cells in Lamina propria

–Crypt abscess

–Depletion of goblet cell mucin

–With time – dysplasia

Symptoms

• Main Symptoms–Rectal Bleeding– Tenesmus–Mucous discharge

• Pain is Unusual

• Others

– Extensive cases – extra-intestinal manifestations

–Anaemia, Hypoprotinaemia and Electrolytes imbalance due to Diarrhea

Proctitis

• 50% have rectal inflammation• Troubles – tenesmus and urgency• No systemic upsets• 5-10% involves the rest of the colon

Colitis

• Clinical patterns ––Bloody diarrhoea up to 20 times–Dehydration– Fluid and electrolytes imbalance–Anaemia–hypoproteinaemia

• Diarrhoea indicates active disease proximal to the rectum

• Increased tendency to systemic upsets• Bleeding --- Protien loss --- Weight loss• Greater risk of extra-intestinal

manifestation and cancer• 30% - inflammation extending up to

Sigmoid colon• 20% - Up to splenic flexure

Colitis Severity Classification

• Mild

• Moderate

• Severe

• Fulminant

• Mild

– fewer than 4 stools daily

–With or without bleeding

–No systemic signs and symptoms

– ESR - normal

• Moderate

–More than 4 stools daily

– Fewer signs of systemic illness

–Mild anaemia

–Abdominal pain may be present

–Raised ESR and CRP

• Severe

–More than 6 bloody stools per day

– Systemic illness – fever, tachycardia, anaemia

–Raised Inflammatory markers

–Hypoalbuminaemia is common

• Fulminant disease–More than 10 bowel movements daily– Fever, tachycardia, continuous bleeding,

anaemia–Hypoalbuminaemia–Abdominal tenderness and distension–Progressive colonic dilation(Toxic Mega

Colon)• Very significant finding• Indication for immediate surgery to avoid

perforation

Extra-intestinal manifestations

• Arthritis–15% of patients – Large joint polyarthropathy type–Affecting knees, ankles, elbows, wrists– Sacroiliatis and ankylosing spondylitis are 20

times common than general population

• Sclerosing cholangitis–Progress to cirrhosis and hepatocellular

failure• Skin lesions– Erythema nodosum and pyoderma

gangrenosum• Eyes –Uveitis and episcleritis

Complications of UC

• Acute– Toxic dilatation

–Perforation

–Haemorrhage

• Chronic–Cancer

– Extra-alimentary manifestations• Skin lesions, • eye problems, • liver diseases

Acute colitis

• Fulminating colitis and toxic dilatation ( megacolon)

• 5-10%• Present with– Severe bowel symptoms–Dehydration and systemic upset

• Dilatation – Suspected in acute colitis with severe

abdominal pain–Plain X-ray abdomen showing colon with a

diameter of more than 6 cm• Plain abdominal radiographs should be

obtained daily in patients with severe colitis,

• A progressive increase in diameter in spite of medical therapy is an indication for surgery

Perforation

• Colonic perforation in UC is grave complication.

• Mortality – 40% • Perforation sometimes may occur

without dilatation

Haemorrhage

• Severe rectal bleeding is uncommon

• Occationally require transfusion

• Rarely surgery

Investigations

Endoscopy and Biopsy

• Rigid/Flexible sigmoidoscopy– Can detect proctitis– Mucosa – hyperaemic , bleed on touch, purulent

exudate– Presence of regenerative mucosal nodules or

polyps

• Colonoscopy and biopsy–Key role in Dx & Mx of UC– To establish the extent of inflammation– To distinguish between UC and CD– To monitor the treatment of Disease– To assess long-standing case for malignant

change

UC CDMacroscopic

Distribution

RectumPerianal diseaseFistula formation

Stricture

Colon/ Rectum

Always involvedRareRareRare

Anywhere in the GI tractOften sparedCommon CommonCommon

Microscopic

Layer involvedGranulomas

FissuringCrypt abscess

Mucosa/submucosaNo NoCommon

Full thicknessCommonCommonRare

Radiology

• Plain abdominal film – Indicates severity of disease in acute setting–Valuable in demonstrating toxic mega colon– Small bowel loops in RHC – sign of severe

disease

• Barium Enema– Gives excellent view of loss of haustra , especially

in the distal colon, pseudopolyps– Chronic cases – narrow, shorten, featureless

‘hosepipe’ colon.

• CT– Pancolitis – significant thickening of colonic wall

Bacteriology

• To exclude infective colitis

Treatment

• Effective management of UC requires multidisciplinary approach.

• Involves gastroenterologist, nurses, nutritionist, enterostomal therapists and occasionally clinical psychologists and social workers, as well as the surgeon

Medical Treatment• Based on anti-inflammatory agents• Non-specific anti-diarrhoeal agents have

no place in the routine management of UC

• 5-aminosalicylic acid (5ASA) derivatives such as Mesalazine – Topically (per rectum)– Systemically

• Can be used long term as maintainance

• Corticosteroids– Topically– Systemically

• Mainstay treatment for any “Flare-up”

Tx of Proctitis

• Acute attack – rectal steroids

• To maintain remission – 5-ASA compounds

• Surgery – very unusual for purely rectal disease

Acute colitis

• Mild attack – respond to oral steroids over 3-4 weeks

period. One of 5- ASA can be given together.

• Moderate attack –Oral Steroid + 5-ASA + twice daily steroid

enema

• Severe attack – Emergency–Requires admission– Stool chart and –Plain X-ray abdomin daily for toxic mega

colon–Anaemia – correct– Fluid and electrolytes – balance–Nutrition– I.V. Hydrocortisone four times daily as well

as rectal steroid

–No evidence that antibiotics modify the course of severe attack– If no improvement within 48 hours of high

dose steroids, – Surgery should be seriously considered–Advisable at day 3-5– Some Gastroenterologists give azathioprin,

cyclosporin A and infliximab to induce remission in severe attack

Operative Treatment

• Emergency• Elective

Emergency

• First Aid Procedure– Sub-total colectomy and end ileostomy

Elective

• Subtotal colectomy and end ileostomy• Protocolectomy and permanent end

ileostomy• Restorative protocolectomy with ileoanal

pouch• Subtotal colectomy and ileo-anal

anastomosis

Differences between Ulcerative colitis and

Crohn’s disease

• Ulcerative colitis affects the colon; Crohn’s disease can affect any part of the gastrointestinal tract, but particularly the small and large bowel

• UC is a mucosal disease, whereas CD affects the full thickness of the bowel wall

• UC produces confluent disease in the colon and rectum, whereas CD is characterized by skip lesions

• CD more commonly causes stricturing and fistulation

• Granulomas may be found on histology in CD, but not in UC

• CD is often associated with perianal disease, whereas this is unusual in UC

• CD affecting the terminal ileum may produce symptoms mimicking appendicitis, but this does not occur in UC

• Resection of the colon and rectum cures the patient with UC, whereas recurrence is common after resection in CD

Thank You