Ulcerative Colitis
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Commoner than Crohn's disease
Recurrent inflammatory disease of the large bowel
Always involves the rectum
Spreads in continuity proximally to involve a variable amount of the colon.
Never spreads beyond the ileocaecal valve ( may get backwash ileitis)
Commonest cause of prolonged bloody diarrhoea (outside the Tropics)
More common in non-smokers
More common in women
Cause
 Unknown
 Some degree of genetic susceptibility
 No evidence of infective agent
Symptoms
 Sometimes none
 Gradual onset (or acute) of rectal bleeding
 Diarrhoea
 Abdominal Pain
(mimicking GI infection)
Proctitis (only rectum involved)
 Constipation with blood on the stool
More extensive disease
 Severe diarrhoea (nocturnal - with urgency and tenesmus)
 Weight loss
 Fever
 Symptoms of hypoproteinaemia
 Symptoms of anaemia
Fulminant colitis
 Liquid stool mixed with blood and pus
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Extra-intestinal manifestations
Signs
Few if chronic
 Clubbing
Fulminant
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Fever
Tachycardia
Hypotension
Weight loss
Dehydration
Tender colon
Extra-intestinal manifestations
Diagnosis
 Sigmoidoscopy
 Red, raw mucosa
 Contact bleeding
 Inflammatory 'pseudopolyps' due to confluent ulcers
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Rectal biopsy
 Inflammatory infiltrate
 Mucosal ulcers
 Crypt abscesses
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Abdominal X-Ray
 Colonic dilatation (+/- perforation) in fulminant disease
 Absent faeces implies involvement
Barium enema
 Fuzzy mucosal margins
 Pseudopolyps
 Ulceration
 If chronic - Colon shortening and loss of haustrae
(never do a barium enema if severe - risk of perforation)
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Stool culture
Microscopy
 Exclude infectious cause
Differential Diagnosis
 Crohn's
 Ischaemic colitis
 Infection
- Pseudomembranous colitis
- Shigella
- Campylobacter
- E Coli
- Cryptosporidium
- other if immunocompromised
Complications
 Haemorrhage
 Dehydration
 Toxic dilatation
 Perforation
 Colon cancer (increased risk with increased duration and extent) - surveillance with
frequent biopsies may reveal occult cancers.
 Liver involvement - e.g. fatty liver, hepatitis, PSC
Medical Management
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Managing Acute Relapses
1. Oral prednisolone
2. Daily steroid enemas
3. Reduce steroids if improving, increase dose if not
4. If systemically unwell - admit to hospital
5. Cyclosporin may be useful (watch renal function)
5-day regimen for Severe Colitis
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Get expert help. Inform surgeons
Nil by mouth. Set up IVI
Chart TPR, BP
2xdaily physical examination. Record stool frequency/character
Daily: FBC, U&E, plain films, abdominal girth
Hydrocortisone IV plus 2 hydrocortisone acetate foam enemas/day
Consider IV nutrition. IM vitamins
If improved transfer to oral prednisolone after 5 days, plus sulfasalazine.
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Indications for Colectomy:
- Deteriorating colitis after 5 days
- 'Toxic' dilatation of colon (megacolon)
- Perforation
Surgical mortality 2-7%
Mortality with perforation 50%
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Maintaining Remissions
Sulfasalazine - lowers relapse rate by 65%. (SE: rash, male infertility, agranulocytosis,
folate deficiency)
Mesalazine - not as effective, but less side effects
Olsalazine - (as Mesalazine)
Long term Azathioprine may reduce need for steroids
Surgery
 Proctocolectomy and ileostomy
 Ileorectal anastomosis
 Pouch formation
Indication: failed medical therapy or complications