Ulcerative Colitis

Part of the inflammatory bowel disease (IBD) collection. The etiology is unknown, but likely has a link to genetics and environmental conditions

Epidemiology (1)

  • 156-291 persons per 100,000 persons per year
  • Bimodal distribution: Ages 15-30, 50-70

Symptoms

  • Diarrhea +/- blood
  • Colicky abdominal pain
  • Urgency, tenesmus (constant feeling of needing to pass stools despite emptiness)
  • Systemic symptoms (fever, fatigue, weight loss)

Diagnosis

  • Rule out other diseases
    • Amebiasis (based on travel history), C. diff (prior antibiotic use), proctitis (sexual history), colonic ischemia (atherosclerotic disease), radiation/NSAID colitis (history), CMV colitis (history of immunosuppression), or salmonella/shigella/campylobacter/yersinia (routine stool cultures)
  • Laboratory findings
    • Anemia
    • ESR, CRP elevations
    • Fecal calprotectin (+): This is a protein found largely in neutrophils, its presence in the stool is sensitive for Inflammatory Bowel Disease (but not Ulcerative Colitis in particular). This test also lacks specificity. (2)
    • Alkaline phosphatase elevation (if PSC is present)
  • Colonoscopy
    • If a patient is hospitalized with severe disease, do a flexible sigmoidoscopy instead of a colonoscopy, as a colonoscopy can precipitate toxic megacolon
    • Findings: Active, circumferential, non-transmural, continuous inflammation, always involves rectum, does not involve small bowel
  • Biopsy
    • Crypt abscesses, crypt branching, crypt atrophy

Treatment

  • Mild-moderate proctitis or proctosigmoiditis: Start with a topical 5-ASA (Mesalamine, Sulfasalazine foams/enemas)
  • Disease extends past rectum: add an PO 5-ASA +/- topical steroids (foams, enemas)
  • Refractory: Oral glucocorticoids, taper after 2-4 weeks of stable therapy
  • Surgery indications:
    • Failed medical management
    • Perforation, hemorrhage, or toxic megacolon
    • Dysplastic/adenomatous polyps
    • Disease lasting >10 years
  • Primary Prevention:
    • Influenza and pneumonia immunizations
    • Regular colon cancer screening
      • If symptoms for 8+ years: colonoscopy every 1-2 years (3)
    • Osteoporosis screening – can supplement with calcium and vitamin D if the patient is on steroids
    • Regular lab-work to screen for electrolyte derangements and anemia

Complications

  • Fulminant colitis/Toxic Megacolon: colon diameter >6cm (or cecal diameter >9cm) + systemic toxicity
  • Primary Sclerosing Cholangitis: May be asymptomatic with an isolated elevation in alkaline phosphatase, or may present with fatigue, pruritus, fevers, chills, and RUQ pain
  • Colon Cancer: Risk of 2% at 10 years after diagnosis, and risk increases by ~1% each year (4)
  • Anemia (Iron Deficiency vs. Anemia of Chronic Disease)
  • Osteoporosis
  • Ankylosing spondylitis
  • Uveitis (conjunctival injection and anterior chamber cloudiness), episcleritis (episcleral vessel injection with normal sclera)
  • Erythema nodosum: Tender subcutaneous nodules on the shins
  • Pyoderma gangrenosum: Red/purple papules that ulcerate and have a blue-violet border

References

  1. Lynch, W. (2020, June 18). Ulcerative Colitis. Retrieved December 28, 2020, from https://www.ncbi.nlm.nih.gov/books/NBK459282/
  2. Pathirana, W., Chubb, S., Gillett, M., & Vasikaran, S. (2018, August). Faecal Calprotectin. Retrieved December 28, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6370282/
  3. The Risk of Colorectal Cancer in Crohn’s Disease and Ulcerative Colitis Patients. (n.d.). Retrieved December 28, 2020, from https://www.crohnscolitisfoundation.org/what-is-ibd/colorectal-cancer
  4. Lakatos, P., & Lakatos, L. (2008, July 7). Risk for colorectal cancer in ulcerative colitis: Changes, causes and management strategies. Retrieved December 28, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2725331/

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