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₎

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 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

Lynch, W. (2020, June 18). Ulcerative Colitis. Retrieved December 28, 2020, from https://www.ncbi.nlm.nih.gov/books/NBK459282/
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/
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
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/