Ulcerative colitis is an inflammatory bowel disease affecting the colonic mucosa, presenting with bloody diarrhea, arthritis, and mild abdominal cramps. It is diagnosed with colonoscopy and treated with immunosuppresants and surgery.

Pathophysiology

• Inflammation of the colonic mucosa and submucosa -> erythematous, granular, and friable membrane
  • Originates in the rectium and extends proximally
  • Loss of vascular pattern and scattered hemorrhaging
  • Severe stages: large mucosal ulcers with purulent exudate
• Sharp border between diseased area and normal area

Contextual Factors

• Family history of ulcerative colitis

Clinical Manifestation

General

• Fever
• Anemia
• Anorexia
• Weight loss

Abdominal

• Episodes of bloody diarrhea
• Fecal urgency4
• Lower abdominal cramps
• Blood/ mucus in the stool

Complications

• Colon cancer

Toxic Colitis/ Fulminant Colitis

1. Stop antidiarrheals
2. NPO and NG placed to suction for decompression
3. Aggressive IV fluid and electrolytes
4. Inflammatory response suppression

• High-dose IV corticosteroids or cyclosporine
• Infliximab

5. Antibiotics (metronidazole, ciprofloxacin)
6. Surgery if poor improvement after 48 hours

Diagnosis

Labs

• Rule out infectious causes (C. diff): stool cultures
• Screening for:
  • Anemia
  • Hypoalbuminemia
  • Elecrolyte abnormalities
• Liver enzyme tests:
  • Elevated alkaline phosphatase and GGT suggest possible primaryu sclerosing cholangitis
• Antibodies specific to ulcerative colitis:
  • Perinuclear antineutrophil cytoplasmic antibodies

Imaging

• Sigmoidoscopy with biopsy
• Abdominal x-ray can show some abnormalities, but is not a great diagnostic indicator
  • Shortened, rigid colon with atrophic/ pseudopolypoid mucosa
  • Intestinal ischemia or Crohn’s colitis: thumbprinting and segmental distribution

Treatment

• Very similar treatment to Crohn’s disease

Acute Flare-Up

• High-dose corticosteroids

Lifestyle

• Dietary management: limiting raw fruits and vegetables, milk
• Immunisations
• Regular cancer screenings
• Smoking is protective but has many risks that outweigh the benefits

Mild Disease

• 5-aminosalicylic acid: blocks prostaglandin and leukotriene production, reducing inflammatory response
• Initially high dose given then tapered once stable

Moderate/ Extensive Disease

• Immunomodulating medications
  • Azathioprine
  • 6-mercaptopurine
• Biologic agents: all the -mabs

Severe Disease

• Trial of biologic agents with or without corticosteroids for 3-7 days
• IV cyclosporine if poor response, then oral cyclosporine for 3-4 months if responsive
  • Alternatively can use tacrolimus

Surgery

• Done for unresponsive severe disease
• Total proctocolectomy with ileal pouch-anal anastomosis (IPAA)
• Curative due to localisation of ulcerative colitis

Supportive

• Loperamide, except during severe flare-up which may result in toxic colitis