Write a Review
x
Feedback General Surgery

Ulcerative Colitis

  • Relapsing and remitting inflammatory disorder of the colonic mucosa.
  • Can just affect the rectum (proctitis); extend to involve part of the colon (left-sided colitis); or the entire colon (pancolitis)

Epidemiology

  • Most common in developed countries – in Caucasians, Ashkenazi Jews
  • All ages are susceptible but found most frequently in patients <30 years old
  • More common in non smokers

Etiology

  • Unknown etiology but is associated with several risk factors
  • Family history of inflammatory bowel disease
  • Associated with HLA DR2
  • Dietary factors – red meat, allergy to cows’ milk
  • Exacerbated by stress

Pathology

  • UC develops as a result of an environmental trigger in a genetically susceptible person
  • Starts in the rectum and spreads proximally – rectum is involved in all circumstances
  • Ulcerative colitis (UC) is a diffuse inflammatory disease which primarily affecting the mucosa and submucosa
    • In comparison to Crohn’s disease which affects all layers of the bowel wall
  • Characteristically presents as multiple minute ulcers (pin-point ulcers)
    • In between the ulcers, the epithelium thickens, which gives the appearance of polyps(pseudopolyps)
  • Severe fulminant colitis
    • Section of the colon (most commonly the transverse colon) becomes acutely dilated with risk of perforation (toxic megacolon)

Histology

  • Inflammatory cells in lamina propria
  • Walls of the crypts are infiltrated by inflammatory cells (crypt abscess)
  • Depletion of goblet cell mucin
  • With time precancerous changes can develop

Clinical features

  • Episodic or chronic diarrhoea – with or without blood and mucus
  • Crampy abdominal discomfort
  • Bowel frequency, urgency, tenesmus
  • Systemic features – fever, malaise, anorexia, weight loss
  • Extra-intestinal signs
    • Clubbing, aphthous oral ulcers, erythema nodosum, pyoderma gangrenosum, conjunctivitis, arthritis

Investigations

  • Blood – FBC, ESR, CRP, U+E, blood culture
  • Stool – to exclude Campylobacter, C.difficile, Salmonella, Shigella, E.coli
  • XR-ray – no faecal shadows, mucosal thickening, colonic dilation, perforation
  • Barium enema – never perform during acute attacks
  • Colonoscopy shows disease extent and allows biopsy – look for inflammatory infiltrate, goblet cell depletion, glandular distortion, crypt abscesses

Treatment

Medical

  • Systemic corticosteroids – for acute exacerbations
  • Sulfasalazine/mesalamine – mainstay of treatment,
  • Immunomodulators – azathioprine
  • Infliximab – anti-TNFa

Surgical

  • Often curative (unlike CD), involves total colectomy
  • Total proctocolectomy with ileo-anal anastomosis with pouches as reservoir
  • Total proctocolectomy with ileostomy
  • Total colectomy
  • Indications for surgery
    • Unresponsive to medical therapy
    • Toxic megacolon (risk of perforation), obstruction due to stricture, severe haemorrhage, perforation
    • Fulminant exacerbation that doesn’t respond to steroids
    • Evidence of increased risk of colon cancer
    • Growth failure or failure to thrive

Complications

  • Perforation and bleeding
  • Toxic megacolon
  • Venous thrombosis
  • Colonic cancer – risk is 15% with pancolitis for 20 years
  • Strictures – benign and malignant
  • Cholangiocarcinoma – half of all bile duct cancers assoc with UC
Feedback