Ulcerative colitis

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Ulcerative colitis
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Disease distribution
Ulcerative Colitis
Left sided cloitis
Proctosigmoiditis
Proctitis
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Disease distribution

• The disease typically is most severe distally and
  progressively less severe more proximally.
• In contrast to Crohn's disease, continuous and
  symmetrical involvement is the hallmark of UC,
  with sharp transition between diseased and
  uninvolved segments of bowel

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Clinical Features
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Systemic manifestations
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Clinical Features
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Physical findings

• mild or even moderately severe disease
  - few abnormal physical signs
• severe attacks
  -tachycardia
  
  -fever
  
  -orthostasis
  
  -weight loss
• fulminant colitis
  
  - the abdomen often becomes distended and firm,
  with absent bowel sounds and signs of peritoneal
  inflammation.

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Laboratory Findings
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Laboratory findings
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Natural history Prognosis
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Natural history Prognosis
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Natural history Prognosis
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Colectomy in Ulcerative colitis

• The probability of colectomy is highest in the
  first year of diagnosis
• the overall colectomy rate is 24 at 10 years and
  30 at 25 years
• The probability of colectomy is related to the
  extent of disease at diagnosis.

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Exacerbating factors
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Diagnosis

• No single test allows the diagnosis of UC with
  acceptable sensitivity and specificity.
• the diagnosis relies on a combination of
  
  -compatible clinical features
  
  -endoscopic appearances
  
  
  -histologic findings.
• Stool cultures should be obtained to exclude
  infectious colitis

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Diagnosis

• colonoscopy should be performed to establish the
  extent of the disease and to exclude Crohn's
  disease.
• Multiple biopsy specimens should be taken from
  throughout the colon to map the histologic extent
  of disease and to confirm the diagnosis if there
  is concern about Crohn's disease.
• Additionally, intubation and biopsy of the
  terminal ileum should be attempted to exclude the
  presence of Crohn's disease.

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Endoscopic findings
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Endoscopic findings
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ENDOSCOPIC SPECTRUM OF SEVERITY
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Endoscopic findings
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Endoscopic findings

• Strictures occasionally may be present in
  patients with chronic UC
• Caused by focal muscular hypertrophy associated
  with inflammation.
• Malignancy must be excluded in patients with UC
  who have strictures, particularly those with long
  strictures without associated inflammation and
  those proximal to the splenic flexure.

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Radiology Barium enema

• less frequently used in the care of patients with
  UC
• may be superior to colonoscopy for certain
  indications

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Radiology Plain film of the abdomen
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Assessment of disease severity

• Mild
  lt4
  stools/day, without or with only small amounts of
  mucus
• No blood
  No
  fever
  No
  tachycardia
  Mild anemia
  
  ESR lt 30 mm/hr
• Moderate
  Intermediate
  between mild and severe
• Severe
  gt6
  stools/day, with blood
  Fever gt 37.5C
  
  Heart rate gt 90 beats/min
  
  Anemia with hemoglobin lt 75 of normal

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Mayo score

• A numerical disease activity instrument
• It is the sum of scores from four components
• It ranges from 0 to 12, with the higher total
  score indicating a more severe disease

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Mayo score
Score Variable
Stool frequency
Normal 0
1-2 stools/day gt normal 1
3-4 stools/day gt normal 2
gt4 stools/day gt normal 3
Rectal Bleeding
None 0
Streaks of blood 1
Obvious blood 2
Mostly blood 3
Score Variable
Mucosal Appearance
Normal 0
Mild friability 1
Moderate friability 2
Exudation, spontaneous bleeding 3
Physician Global Assessment
Normal 0
Mild 1
Moderate 2
Severe 3
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Mayo score

• Remission score lt2
• severe disease scoregt 10
• Clinical response decrease by 3 points from the
  patient's initial baseline score.

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Fulminant colitis

• Patients with severe fulminant colitis
  
  - appear toxic
  
  -fever higher than 101F
  
  -tachycardia
  
  - abdominal distention
  
  -signs of localized or generalized
  peritonitis
  -leukocytosis
• Toxic megacolon radiologic evidence of colon
  dilatation to greater than 6 cm in an acutely ill
  patient.
• Fulminant colitis and toxic megacolon are
  clinical diagnoses, and endoscopic examination
  should be avoided in patients with severe or
  fulminant colitis because of the risk of inducing
  megacolon or perforation.

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Differentiating crohns disease from ulcerative
colitis
Ulcerative colitis Crohns disease Variable
Continuous, symmetric, and diffuse, with granularity or ulceration found throughout the involved segments of colon periappendiceal inflammation (cecal patch) is common even when the cecum is not involved Often discontinuous and asymmetric with skipped segments and normal intervening mucosa, especially in early disease Distribution
Typically involves the rectum with proximal involvement to a variable extent Completely, or relatively, spared Rectum
Not involved, except as backwash ileitis in ulcerative pancolitis Often involved (75 of cases of Crohn's disease Ileum
Mucosal not transmural except in fulminant disease Submucosal, mucosal, and transmural Depth of inflammation







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Differentiating crohns disease from ulcerative
colitis
Ulcerative colitis Crohns disease Variable
Rarely present suggestive of adenocarcinoma Often present Strictures
Not present, except rarely for rectovaginal fistula Perianal, enterocutaneous, rectovaginal, enterovesicular, and other fistulas may be present Fistulas
Generally not present Present in 15-60 of patients (higher frequency in surgical specimens than in mucosal pinch biopsies) Granulomas
pANCA positive in 60-65 ASCA positive in 5 pANCA positive in 20-25 ASCA positive in 41-76 Serology

Often present Strictures






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Extraintestinal manifestations of IBD
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Extraintestinal manifestations

• numerous complications may occur distant from the
  bowel
• Many of these complications are common to both
  Crohn's disease and ulcerative colitis
• In large series, extraintestinal manifestations
  are found to occur more frequently in Crohn's
  disease than in ulcerative colitis and are more
  common among patients with colonic involvement
  than in patients with no colonic inflammation
• one fourth of all patients with Crohn's disease
  will have an extraintestinal manifestation of IBD.

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Extraintestinal manifestations of IBD
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Musculoskeletal Manifestations

• Among the most common extraintestinal
  manifestations are disorders of the bones and
  joints
• In most patients, joint symptoms occurred in the
  setting of a relapse of bowel symptoms
• Among patients with Crohn's disease, nearly one
  half had joint symptoms in association with a
  relapse in bowel disease.

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Musculoskeletal Manifestations
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Peripheral arthropathy
Type2 Type1 Features
gt5 lt5 Number of joints affected
Mainly small joints Mainly large joints Joints affected
Symmetrical Asymmetrical Joints affected
Independent Parallel Association with bowel disease activity
Months to years (median 3 yr) lt10 wk (median 5 wk) Duration of attacks
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Musculoskeletal Manifestations

• Axial arthropathy occurs less frequently than
  does peripheral arthropathy in patients with IBD,
  and includes sacroiliitis and spondylitis.
• Spondylitis associated with IBD presents as
  insidious low back pain and morning stiffness
  that is improved by exercise.
• Does not parallel the activity of bowel disease

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Skin pyoderma gangrenosum

• The most common skin lesions associated with IBD
  are pyoderma gangrenosum and erythema nodosum.
• Neither condition is found solely in IBD, and the
  finding of one or the other lesion is not
  specific for either major form of IBD.

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Skin pyoderma gangrenosum

• Pyoderma gangrenosum appears first as a papule,
  pustule, or nodule and progresses to an ulcer
  with undermined borders. The ulcer typically has
  a violaceous rim and crater-like holes pitting
  the base
• most often appears on the leg however it can
  occur virtually anywhere on the body.
• Rare, occurs in 1-2 of patients
• In Crohn's disease pyoderma gangrenosum often
  occurs without an associated flare of bowel
  symptoms.

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Skin pyoderma gangrenosum
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Skin erythema nodosum
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Erythema nodosum
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Mucocutaneous Manifestations

• Aphthous ulcers of the mouth are common among
  patients with Crohn's disease and ulcerative
  colitis
• These lesions usually occur with flares of
  colitis and resolve on control of the bowel
  disease
• Angular cheilitis is seen in nearly 8 of
  patients with Crohn's disease.
• Angular stomatitis and a sore tongue may be seen
  in patients with deficiencies of iron or other
  micronutrients

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Ocular Manifestationsepiscleritis

• estimated to occur in 6 of patients with Crohn's
  disease, 5 of patients with ulcerative colits
• consists of painless hyperemia of the sclera and
  conjunctiva with no affection of visual acuity.
• It typically parallels the activity of bowel
  disease and usually responds to anti-inflammatory
  therapy

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Ocular Manifestations uveitis

• uveitis presents as an acute or subacute painful
  eye with visual blurring and often photophobia
  and headache. Visual acuity is preserved unless
  the posterior segment becomes involved.
• Temporal correlation of uveitis with the activity
  of the colitis is less predictable than with
  episcleritis.
• Uveitis should receive prompt treatment with
  local steroid ocular drops to prevent progression
  to blindness.

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Hepatobiliary Manifestations

• Gallstones are found in more than 25 of men and
  women with Crohn's disease, representing a
  relative risk of 1.8 compared with the general
  population.
• Asymptomatic and mild elevations of liver
  biochemical tests often are seen in IBD. In most
  cases, the levels return to normal once remission
  is achieved. These abnormalities are thought to
  be related to a combination of factors, including
  malnutrition, sepsis, and fatty liver.
• Primary sclerosing cholangitis more often is
  associated with ulcerative colitis but may occur
  in 4 of patients with Crohn's disease, usually
  those with colonic involvement.

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Hepatobiliary Manifestations PSC

• PSC should be excluded in patients with UC who
  have persistently abnormal liver tests or
  evidence of chronic liver disease.
• PSC is independent of the underlying colitis and
  it usually follows a progressive course after
  many years of stable disease.
• Unfortunately, no treatment has been shown
  definitively to be effective.

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Renal and Genitourinary Manifestations

• uric acid and oxalate stones are common in
  patients with Crohn's disease. In the setting of
  fat malabsorption resulting from intestinal
  resection or extensive small bowel disease,
  luminal calcium binds free fatty acids, thereby
  decreasing the calcium that is available to bind
  and clear oxalate. Increased oxalate is absorbed
  as the sodium salt, resulting in hyperoxaluria
  and calcium oxalate stone formation.
• Uric acid stones are believed to result from
  volume depletion and a hypermetabolic state.
• More rare complications include membranous
  nephropathy, glomerulonephritis, and renal
  amyloidosis..

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Coagulation and Vascular Complications

• The occurrence of hypercoagulability is a
  well-recognized complication of IBD.
• Patients may present with venous thromboembolism
  or, much less commonly, arterial thrombosis.
• The hypercoagulable state is multifactorial.
• A variety of coagulation and platelet
  abnormalities may be present in patients with UC,
  particularly those with severe disease, and
  include
  -
  thrombocytosis
  
  - increased levels of fibrinogen,
  coagulation factors V and VIII and plasminogen
  activator inhibitor
  
  -decreased levels of antithrombin III, proteins C
  and S, factor V Leiden, and tissue plasminogen
  activator.

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Serological markers in IBD

• CRP
• P-ANCA
• ASCA

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Serological markers in IBD

• May be useful in predicting the phenotype of
  crohns disease
• There are association between ASCA and

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Serological markers in IBD

• Patient with positive serology and high titer are
  more likely to have complications