Ulcerative colitis
By Varun Sharma
Intro
One of two major forms of IBD
Considerable overlap in features between UC
and CD
Incidence: 6-15/100 000 people/year
More common in developed Western countries
Aetiopathogenesis?
Genetic: more common amongst relatives of
patients
Environmental: nutrition?, intestinal
microflora?
Immunological: upregulation of immune
system that leads to tissue damage
Pathology
Can affect rectum alone (proctitis),
Or in conjunction with sigmoid and descending colon
(left-sided colitis),
Or whole colon (total colitis)
May afffect teminal ileum (backwash ileitis)
Tends to affect only the mucosa and submucosa
Clinical features
Diarrhoea with blood and mucus
Lower abdominal discomfort
Malaise, lethargy, anorexia, fever
Aphthous ulceration in the mouth
Proctitis: urgency, tenesmus
Acute attack: 10-20 liquid stools/day, urgency and
incontinence (esp. at night)
Extra-GI features
Eyes: uveitis, episcleritis, conjunctivitis
Joints: arthropathy, ankylosing spondylitis
Skin: erythema nodosum, pyoderma gangrenosum
Liver and biliary: sclerosing cholangitis, fatty liver
Venous thrombosis
Investigations
Bloods – anaemia, WCC, platelets, ESR, CRP,
LFT’s, pANCA
Stool cultures – exclusion
Imaging – plain AXR, US and CT
Rigid sigmoidoscopy – inflamed, bleeding, friable
mucosa
Medical Management
Mild: prednisolone and mesalazine for 2 weeks
Moderate: 5 weeks prednisolone, 5-ASA and
twice-daily steroid enemas (budesonide)
Severe: hydration, IV hydrocortisone, rectal
hydrocortisone, monitoring
Surgical management
Indications:
Acute: failure of medical treatment, toxic
dilatation, haemorrhage, perforation
Chronic: incomplete response to medical
treatment, excessive steroid requirement, non-
concordance, risk of cancer
Surgical Managment
Total proctocolectomy and ileostomy
More modern management: ileo-anal pouch
formation – continence restoring procedure
(sphincters intact)
‘J’, ‘S’ or ‘W’ folding of the distal ileum to
form faecal reservoir – ‘pouchitis’ vs reservoir
performance and failure rates
Surgical Management
Follow-up:
Annual endoscopy for 1st five years as residual
colonic mucosa is at risk of neoplastic
transformation
Pouchitis with villous hypertrophy and dysplasia
Surgical Management
Complications:
Anastomotic leak ± pelvic abscess
Pouchitis: increased stool frequency, malaise, fever, or
incontinence – antibiotic therapy
C. difficile and C. perfringens infections are more likely
Fistula formation (pouch-vaginal, pouch-anal,
enterocutaneous at 1% each)