Ulcerative Colitis

Definition

Normal mucosa in the transverse part of the colon to the left. Mild to moderate inflammation in ulcerative colitis to the right.

Symptoms

Severe ulcerative colitis in rectum (to the left) and in sigmoid colon (to the right)

Diagnosis

Colonoscopy is the main diagnostic tool in the diagnostic workup when ulcerative colitis is suspected

History and clinical examination are the two most important diagnostic tools in medicine, and a preliminary diagnose can often be made with these. Rigid or flexible sigmoideoscopy and colonoscopy are the main diagnostic means in confirming the diagnose. Laboratory tests show anaemia, leucocytosis, high platelets, low albumin and high CRP (C-reactive protein) and ESR (Erythrocyte sedimentation rate). Infectious colitis should be ruled out by stool cultures.

Classification of severity

The classic Truelove & Witts classification of the severity of ulcerative colitis (modified)

Extent of the disease

Ulcerative proctitis

The mildest form of ulcerative colitis affects only the rectum, less than 15 cm above the anal margin, often only about 8 cm of the distal rectum.

Proctosigmoiditis, endoscopic findings in the sigmoid colon

The disease is called proctosigmoiditis, when it affects only the rectum and sigmoid colon (Sigmoideum).

Left-sided colitis affects the colon up to the splenic flexure (Flexura lienalis).

Inflammatory polyps in the colon, a frequent but innocent finding in ulcerative colitis

Extensive colitis affects the colon above the splenic flexure up to the hepatic flexure (Flexura hepatis). This form of ulcerative colitis is also called substantial colitis.

Ulcerative colitis, endoscopic findings in caecum

Pancolitis involves the entire colon from rectum to caecum (also called total colitis).

The large bowel, colon, and its parts

A rare form of ulcerative colitis affects rectum and caecum, while the other parts of the colon are spared.

Differences between ulcerative colitis and Crohn´s disease

Severe inflammatory bowel disease in the sigmoid colon, uclerative colitis to the left and Crohn´s disease to the right

Fistulaes and perianal lesions are more common in Crohn´s disease. The diarrhoea and blood in stools are worse in ulcerative colitis, while pain and fever are more prominent in Crohn´s disease. Patients with Crohn´s disease often have a palpable mass in the abdomen. Crohn´s disease has a pathy appareance and can occur anywhere in the gastrointestinal channel, while ulcerative colitis only affects colon and rectum. Aphthous ulcers and skip lesions surrounded by normal mucosa are a typical colonoscopic finding in Crohn´s disease.

Differential diagnoses

Differential diagnosis: Proctosigmoiditis caused by radiation therapy to the left, rectal cancer in the middle and infectious colitis to the right

Acute infectious colitis (bacterial or viral), colorectal cancer and diverticulitis can cause symptoms similar to ulcerative colitis and should be excluded.

Other differential diagnoses might be pseudomembranous colitis (caused by a clostridium difficile-infection most often after antibiotic therapy), ischaemic colitis and colitis caused by radiation therapy and by drug injury (NSAID´s). The solitary rectal ulcer-disease causes symptoms very similar to ulcerative proctitis.

Patientents with symptoms similar to ulcerative colitis but with a normal finding in colonoscopy could have microscopic colitis (collagenous or lymphycytic colitis).

Pouchitis

Pouchitis

Ulcerative colitis can affect the patient also after colectomy and reconstructive ileoanal anastomosis in the form of pouchitis, an inflammation in the ileal reservoir.

Cancer caused by ulcerative colitis

Colon cancers caused by ulcerative colitis

The risk of malignant transformation is significant when an extensive or total colitis has a duration of 8 years or more. The risk in leftsided colitis gets increased after over 20 years duration of the disease, and ulcerative procitis does not have any increased risk of malignancy.

A DALM-lesion in rectum

A dysplasia associated lesion or mass (DALM) found in a follow-up colonoscopy is a serious finding indicating a 50% risk of malignancy, either in the lesion itself or in any other part of colon.

Scarring

Mucosal scars caused by ulcerative colitis

Extensive mucosal scars are often seen in a longstanding ulcerative colitis. These scars do not generally cause any symptoms.

Treatment

Although the disease is in remission and the patient is free from symptoms small patchy mucosal lesions can be seen in the rectum (to the left) and in the sigmoid colon (to the right)

A mild ulcerative proctitis is usually treated with 5-aminosalicylate or corticosteroid suppositories and a severe proctitis with corticosteroid enemas.

A mild proctosigmoiditis is treated with oral 5-aminosalicylate or with 5-aminosalicylate or corticosteroid enemas. A severe proctosigmoiditis is treated with oral or intravenous corticosteroids.

A mild extensive or total colitis is treated with oral 5-aminosalicylate and a severe disease with oral or intravenous corticosteroids.

In the maintenance treatment oral 5-aminosalicylate is used. If the disease require longstanding corticosteroid treatment, azathioprine can be used in order to lower the required corticosteroid dose. Intravenous cyclosporin is sometimes used if intravenous corticosteroids does not give a satisfactory response.

Surgery is necessary if the disease causes frequent and severe relapses despite the maintenance treatment, and if the disease is complicated with (pre-)malignant lesions.

Videoclip: Fulminant ulcerativive colitis in the sigmoid colon