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Ulcerative Colitis

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... moderate disease involving distal colon to splenic flexure: frequent ... (30% risk of cancer with stricture formation) ... risk of colon cancer ... – PowerPoint PPT presentation

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Title: Ulcerative Colitis


1
Ulcerative Colitis
  • Katherine Doerr

2
Definition
  • An inflammatory bowel disease with recurring
    episodes of mucosal inflammation involving the
    rectum and extending proximally

3
Etiology Epidemiology
  • Dysregulation of the intestinal immune system
  • Environmental, infectious, autoimmune and genetic
    components
  • Family history confers a 3 to 20 times greater
    chance
  • Concordance in twins 6-10

4
Etiology Epidemiology
  • Prevalence 50-80/100,000
  • Incidence 3-15/100,000
  • Peak incidence between 15 and 30 years
  • Second peak between 50 to 80 years
  • Higher incidence in Jewish populations
  • Non gender specific
  • Negative correlation between smoking and
    ulcerative colitis

5
History
  • Severity of inflammation determines presentation
  • With mild disease confined to rectum (ulcerative
    proctitis)
  • insidious onset
  • intermittent rectal bleeding
  • mild diarrhea with or without mucus up to 4
    stools/day
  • mild pain and tenesmus
  • 1/3 of patients to 1/2 of patients

6
History
  • With moderate disease involving distal colon to
    splenic flexure
  • frequent bloody stools
  • mild anemia
  • abdominal pain limited in severity
  • low grade fever
  • 1/3 of patients

7
History
  • With severe disease extending to cecum
    (pancolitis)
  • frequent loose stools, 6/day
  • severe cramping
  • fever to 39.5ºC
  • bleeding requiring transfusion
  • poor nutritional state
  • up to 1/3 of patients

8
History
  • With extremely severe disease
  • decreased colonic motility causing decreased
    number of bowel movements
  • severe bleeding
  • toxic megacolon (fever, abdominal pain,
    dehydration, tachycardia)
  • less than 10 of patients

9
Physical Exam
  • Physical exam
  • can be normal
  • abdominal tenderness
  • pallor
  • weight loss
  • blood on DRE

10
Extraintestinal manifestations
  • uveitis/episcleritis
  • erythema nodosum/pyoderma gangrenosum
  • primary sclerosing cholangitis
  • peripheral arthritis
  • venous/arterial thromboembolism
  • autoimmune hemolytic anemia
  • apthous stomatitis

11
Erythema nodosum
12
Pyoderma gangrenosum
13
Apthous stomatitis
14
Differential Diagnosis
  • Crohns disease
  • Radiation colitis
  • Ischemic colitis
  • Infection (ie. Salmonella, Shigella,
    Campylobacter, E. coli, C. diff)
  • Drugs including NSAIDs, retinoic acid, gold, OCPs
    (?)

15
Labs
  • Decreased hemoglobin, hematocrit
  • Thrombocytosis
  • Elevated ESR
  • Hypoalbuminemia
  • Elevated alk phos with PSC
  • pANCA in 70 patients but not sensitive or
    specific
  • Stool cultures to rule out other dx

16
Diagnosis History, Physical, Endoscopy
Biopsy
17
Flexible sigmoidoscopy
  • mucosal ulceration, exudates, friability
  • dilated mucosal vessels
  • continuous colonic involvement
  • pseudopolyps (reaction to prior inflammation in
    longstanding disease)
  • colonoscopy and small bowel follow through
    required only with uncertain dx
  • avoid colonoscopy or barium enema with extremely
    severe ulcerative colitis

18
Pathology
19
Pathology
20
Biopsy
  • crypt abscesses
  • infiltration of plasma cells, neutrophils,
    lymphocytes, eosinophils
  • atrophy of glands
  • loss of mucin from goblet cells
  • pseudopolyps

21

22
Treatment options
  • Mild disease
  • oral and rectal 5-ASA compounds
  • Moderate disease
  • oral and topical 5-ASA compounds
  • oral steroids
  • azathioprine, 6-MP
  • Severe disease
  • IV steroids
  • Cyclosporine
  • Azathioprine, 6-MP, infliximab
  • Colectomy

23
Indications for proctocolectomy
  • Uncontrolled hemorrhage
  • Severe colitis failing aggressive medical
    management for two weeks
  • Toxic megacolon
  • Bowel perforation
  • Unwanted side effects from prolonged steroids
  • Dysplasia, strictures (30 risk of cancer with
    stricture formation)
  • Debilitating disease refractory to medical
    treatment (FTT in children)
  • Nonemergent

24
Prognosis
  • Proctitis/distal colitis
  • 20 resolve spontaneously
  • Majority in remission with medical therapy
  • Proximal progression up to 15
  • Severe disease
  • Less likely to remit
  • Worse with extremely young and extremely old
  • Surgical intervention required in 30 after 20
    years

25
Additional complications
  • Risk of colorectal cancer in patients with
    recurring disease
  • 5-10 after 20 years
  • 12-20 after 30 years
  • Patients with PSC especially at risk
  • Colonoscopy recommended after 8-10 years disease
    duration with multiple biopsies
  • Repeat every 1-2 years

26
Take home points
  • Ulcerative colitis presents with rectal bleeding
    in 20 or 60 year old
  • Diagnose with flexible sigmoidoscopy
  • Rule out Crohns/infectious process
  • Only mucosal involvement
  • Continuous from rectum extending proximally
  • Treat with 5-ASA, steroids, immune modulation,
    proctocolectomy
  • Recognize increased risk of colon cancer
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