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Ulcerative Colitis

1. Definition

2. Epidemiology

• Increased incidence in Caucasians compared to Afro-Caribbean or Asian populations
• Increased incidence in the Ashkenazi - Jewish population
• The incidence is approximately 10-20:100,000 population per year in the UK
• Prevalence - 100 - 200 per 100,000
• May affect any age group. Bimodal distribution - peaks are ages 15 to 30 and 50 to 70

3. Risk Factors

• Family history - Risk is approximately 10-20% for individuals with a first degree relative
• Smoking is PROTECTIVE against UC.

4. Symptoms and Signs

• Acute severe attack of UC may be defined clinically by the presence of
  • >6 bloody diarrhoeal stools/day (primary symptom)
  • Pyrexia
  • Tachycardia
  • Anaemia
  • Weight loss
  • Abdominal pain/tenderness
• Click here to see the National Association for colitis and Crohn's disease

4.1 Extra-intestinal manifestations of UC

4.1.1 Related to disease activity

• Pyoderma gangrenosum
• erythema nodosum
• mucous apthous ulcers
• iritis
• large joint arthritis

4.1.2 Unrelated to disease activity

• Sacroileitis/ankylosing spondylitis
• chronic active hepatitis
• cirrhosis
• primary sclerosing cholangitis (more common in UC than Crohn's)
• primary biliary cirrhosis
• clubbing

5. Diagnosis + Investigation

• History and Examination
• Digital Rectal Exam (DRE)
• Bloods: Haemoglobin, platelets, ESR,CRP, serum albumin
• Stool culture - MC&S + C-Diff toxin
• Rigid Sigmoidoscopy without excessive air insufflation

• AXR - for colonic dilatation (toxic megacolon) + thumbprinting

• Erect CXR - if you suspect a perforation

• Sigmoidoscopy/Colonoscopy - Extent of colitis + biopsies can to taken to make a histological diagnosis

• Diagnosis is made by combining the history and examination findings with colonoscopy, histology and negative stool samples.

6. Pathology (see table comparing to Crohn's)

6.1 Macroscopic

• Starts from the rectum and spreads proximally involving avariable but continuous length of colon
• May involve the entire colon (pancolitis)
• Ileum involved in one third on cases (backwash ileitis)
• Inflammation and ulceration usually limited to mucosa
• Shallow mucosal ulcers
• Mucosal surface covered in blood and mucous with numerous petechial haemorrhages

6.2 Microscopic

• Distortion of crypt architecture
• Inflammation of the crypts (cryptitis)
• Numerous crypt abscess
• Other rare types include SCC and lymphoma

6.3 Risk of dysplasia or malignant change

• This increases with the length of history
• 7% at 10 years
• 17% at 30 years
• Total colitis patients have a much higher risk than those with only left-sided disease (19 fold versus 4 fold) increase compared to the normal population.

7. Management

7.1 Acute UC

• Treatment is initially supportive
• IV fluid replacement
• Blood transfusion if required
• DVT Prophylaxis
• Nutritional support
• Drugs

7.2 Drugs used to induce remission

• 5-aminosalicylic acid derivatives (e.g. mesalazine (topical or oral), sulfasalazine)
  • induces remission
  • for mild to moderate colitis, is an efffective first line therapy
• Corticosteroids (e.g. iv hydrocortisone, prednisolone (oral or  enemas )
  • used to induce remission.
  • Combination of oral and rectal steroids is better than either alone.
• Thiopurines (e.g. azathioprine)
  • Effective for both active disease and maintaining remission
• Cyclosporin
  • Used as salvage therapy for patients with refractory colitis.
  • Use is controversial due to side effect profile e.g. renal impairment, neurotoxicity, infections

7.3 Maintaining Remission

• Lifelong maintenance therapy generally recommended
• 5-aminosalicylic acid derivatives (mesalazine) - main role in UC is maintenance of remission
• Thiopurines - main role is steroid sparing. Careful monitoring required to look for evidence of bone marrow suppression and hepatotoxicity

7.4 Indications for Surgery

• Patients requiring surgery for IBD should be under joint care of a gastroenterologist and a colorectal surgeon.
• Can be classified into Emergency or Elective

7.4.1 Emergency

7.4.1.1 Indications

• Failure of medical management
• Toxic dilatation
• Perforation
• Bleeding

7.4.1.2 Predictors of Surgery

• Re-evaluation required at day three of admission with acute attack
• Predictors of surgery on day three (85% of cases)
  • CRP >45
  • Stool frequency >8/day

7.4.2 Elective

• Steroid dependence
• Recurrent exacerbations
• Rapidly relapsing disease
• Growth retardation in children
• Malignant transformation
• Cancer prophylaxis

7.5 Surgical Options

7.5.1 Emergency

7.5.1.1 Subtotal Colectomy + end Ilestomy

• Colon removed leaving rectal stump and end ileostomy
• Performed in the emergency situation for UC
• Advantages - Permits ileorectal anastomosis at a later date, or other sphincter preserving surgery
• Disadvantages - will often need >1 operation for persistent proctitis, haemorrhage, cancer prophylaxis/transformation
• click here to see a pathology specimen of fulminant colitis

7.5.1.2 Proctocolectomy + end Ileostomy

• Whole colon + rectum removed and end ileostomy
• Performed if patient adamant that does no require further surgery and happy to manage lifelong stoma
• Advantages - single curative procedure, no further cancer surveillance required
• Disadvantages - permanent end stoma + stoma complications (stenosis, hernia, prolapse)

7.5.2 Elective

7.5.2.1 Completion Proctectotomy/ proctocolectomy + ileoanal pouch reconstruction

• Rectal stump removed (following sub-total colectomy)/ whole colon + rectum removed and ileo-anal pouch formed
• Advantages - no stoma (very important to some patients as leads to improved quality of life), all disease removed, transanal defaecation and faecal continence preserved
• Disadvantages - Pouchitis, nocturnal seepage, increased bowel movements (about 6 times/day), 2nd surgical procedure + complications involved

7.5.2.2 Colectomy and Ileorectal Anastomosis

• Colon removed and ileorectal anastomosis formed
• Advantages - single procedure, no stoma, transanal defaecation and faecal continence preserved
• Disadvantages - Residual rectum with recurrent disease and cancer risk needing surveillance

8. Suggested further reading