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Ulcerative colitis 

Ulcerative colitis

Chapter:
Ulcerative colitis
Author(s):

D.P. Jewell

DOI:
10.1093/med/9780199204854.003.1512_update_001

Update:

Aetiology—expanded discussion of genetic associations; mention of recent report incriminating Campylobacter concisus; description of predisposition caused by antibiotic exposure in early life.

Pathology—discussion of CMV colitis in patients with ulcerative colitis.

Treatment—revision of recommendations, including use of anti-TNF monoclonal antibodies and expanded comment on use of thiopurines and of sulphasalazine.

A relevant case history from Oxford Case Histories in Gastroenterology and Hepatology has been added to this chapter.

Updated on 30 Nov 2011. The previous version of this content can be found here.
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date: 30 March 2017

Ulcerative colitis is a chronic inflammatory disease of the colon that always affects the rectum, extends proximally to a variable extent, and is characterized by a relapsing and remitting course. In mild disease the mucosa is hyperaemic and granular; punctate ulcers appear in more severe disease, and these may then enlarge and extend deeply. Infiltration with acute and chronic inflammatory cells is largely confined to the mucosa, with histological features of chronicity, e.g. distorted crypt architecture, important in clinical distinction from other causes of colitis, e.g. infective.

The cause of ulcerative colitis is unknown: genetic factors are involved although not all the relevant genes are yet identified. A dysregulated immune response to luminal antigen may be important.

Clinical features and investigation

Typical presentation of mild or moderate disease is with a gradual onset of symptoms including diarrhoea, rectal bleeding, the passage of mucus, and—less frequently—abdominal pain; such patients usually look well and exhibit few abnormal physical signs.

Severe disease is characterized by anorexia, nausea, weight loss, and severe diarrhoea (>6 motions daily) that becomes a slurry of faecal material, pus, and blood. The patient is likely to look unwell with fever, tachycardia, and other signs of volume depletion, and the abdomen is often distended and tympanitic, with reduced bowel sounds and marked colonic tenderness.

Extraintestinal manifestations may be related to activity of the colitis (e.g. aphthous ulceration of the mouth, erythema nodosum, peripheral arthropathy, pyoderma gangrenosum) or not (e.g. anterior uveitis, sacroiliitis, primary sclerosing cholangitis). Local colonic complications of acute disease include acute dilatation and perforation, and complications of longstanding disease include carcinoma (7–15% risk after 20 years).

Diagnosis is usually made on the basis of exclusion of infective colitis by stool culture and the finding of typical diffuse sigmoidoscopic appearances in the rectum. All patients with a severe attack require a plain abdominal radiograph, primarily to exclude acute dilatation. Active disease is often accompanied by a neutrophil leucocytosis, thrombocytosis, and a rise in inflammatory markers.

Management

For active disease treatment depends on severity, but initial therapy is usually as follows: (1) proctitis—a 5-aminosalicylic acid drug, given by mouth and concurrently as a suppository; (2) mildly active disease (≤4 motions/day)—high-dose 5-aminosalicyclic acid together with topical steroids; (3) moderately active disease (>4 motions/day, but not systemically ill) – as for mild disease, or prednisolone 40 mg daily; (4) severe disease (>6 bowel motions/day, with blood; systemically ill) – resuscitation/intravenous fluids; hydrocortisone, 100 mg intravenously every 6 h and 100 mg as a rectal drip twice daily; those who deteriorate during the first few days of intravenous treatment, or who have not made a substantial improvement after 3–4 days, need either ‘rescue’ therapy with ciclosporin or an anti-TNF monoclonal antibody, or colectomy. Patients with chronic active disease that prevents steroid withdrawal are treated with immunosuppressants, azathioprine and 6-mercaptopurine being most widely used.

In the long term, drugs containing 5-aminosalicylic acid (e.g. sulphasalazine, mesalazine) reduce the relapse rate and are able to maintain remission over many years. Patients with extensive longstanding disease require regular colonoscopic surveillance, with prophylactic colectomy usually advised if biopsies reveal dysplasia.

Indications for surgery include (1) severe inflammation unresponsive to medical therapy; (2) acute complications (perforation, dilatation); (3) chronic active disease; and (4) prevention of cancer. Restorative proctocolectomy with ileoanal reservoir/pouch is the procedure of choice in specialist centres, provided the anal sphincter is intact.

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