AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Background

Ulcerative colitis (UC) is an idiopathic chronic inflammatory disorder limited to the colon. Ulcerative colitis is a lifelong illness that has a profound emotional and social impact on patients who are affected.

Pathophysiology

The rectum is involved in more than 95% of cases, although some authorities believe that the rectum is always involved in untreated patients. Ulcerative colitis extends proximally from the anal verge in an uninterrupted pattern to involve part or all of the colon.

Frequency

United States

The annual incidence of ulcerative colitis is 10.4-12 cases per 100,000 people. The prevalence rate is 35-100 cases per 100,000 people.

International

Prevalence rates may be lower in South America, Asia, and Africa.

Race

• Ulcerative colitis occurs more frequently in white people.
• The incidence of ulcerative colitis is reported to be 2-4 times higher in Jewish people. However, population studies in North America do not completely support this assertion.

Sex

Ulcerative colitis seems to have a female preponderance. Ulcerative colitis affects 30% more females than males.

Age

The incidence of ulcerative colitis peaks in people aged 15-25 years and in people aged 55-65 years, although it can occur in people of any age.

CLINICAL

Section 3 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

History

• Frequent episodes of rectal bleeding occur, with or without mucus.  The characteristic feature is blood in each bowel movement.
• Urgency and tenesmus
• Abdominal cramps
• Weight loss in severe cases
• Extracolonic manifestations
• • Synovitis
  • Ankylosing spondylitis (HLA-B27)
  • Sacroiliitis
  • Erythema nodosum
  • Pyoderma gangrenosum
  • Aphthous stomatitis
  • Episcleritis
  • Iritis
  • Primary sclerosing cholangitis (PSC)
  • Uric acid renal stones
  • Rarely, thromboembolic events or syndromes (CNS venous thrombosis)

Physical

Physical findings are typically normal in patients with mild disease, except for mild tenderness in the lower left quadrant. 

Patients with severe disease can have signs of volume depletion and toxicity, including the following:

• Fever
• Tachycardia
• Significant abdominal tenderness
• Weight loss

Causes

• Autoimmune phenomena: Serum and mucosal autoantibodies against intestinal epithelial cells may be involved. Persons with ulcerative colitis are often found to have p-antineutrophil cytoplasmic antibodies.
• Immune-mediated phenomena: Abnormalities of humoral and cell-mediated immunity and/or generalized enhanced reactivity against intestinal bacterial antigens may be causes. A loss of tolerance against indigenous enteric flora is believed to be the central event in the pathogenesis of inflammatory bowel disease (IBD). 
• Genetic susceptibility (chromosomes 12 and 16) is a factor associated with ulcerative colitis. A positive family history (observed in 1 in 6 relatives) is associated with a higher risk for developing the disease.
• Smoking is negatively associated with ulcerative colitis. This relationship is reversed in Crohn disease.
• Environmental factors may be involved.
• Dietary factors: Milk consumption may exacerbate the disease.
• Appendectomies have a negative association with ulcerative colitis.

DIFFERENTIALS

Section 4 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Other Problems to be Considered

Infectious colitis
Ischemic colitis in elderly patients
Radiation colitis
Collagenous colitis and lymphocytic colitis (rarely requires surgery, low risk for malignancy)

WORKUP

Section 5 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Lab Studies

• Anemia (ie, hemoglobin <14 g/dL in males and <12 g/dL in females)
• Thrombocytosis (ie, platelet count >350,000/µL)
• Elevated sedimentation rate (variable reference ranges, usually 0-33 mm/h) and elevated C-reactive protein (ie, >100 mcg/L): Both of these findings correlate with disease activity.
• Hypoalbuminemia (ie, albumin <3.5 g/dL)
• Hypokalemia (ie, potassium <3.5 mEq/L)
• Hypomagnesemia (ie, magnesium <1.5 mg/dL)
• Elevated alkaline phosphatase: More than 125 U/L suggests primary sclerosing cholangitis (usually >3 times the upper limit of the reference range).

Imaging Studies

• A plain abdominal radiograph might show colonic dilatation in severe cases, suggesting toxic megacolon. Also, evidence of perforation, obstruction, or ileus can be observed.
• Barium enemas may precipitate toxic megacolon in severe cases. Barium enemas can be performed safely in mild cases. They may show a narrow, tubular, shortened colon with loss of haustral folds, pseudopolyps, and small ulcers.
• CT scan, in general, plays a minor role in the diagnosis of ulcerative colitis. CT scan can show thickening of the colonic wall. Biliary dilatation suggests primary sclerosing cholangitis.

Other Tests

• Stool studies to exclude other causes (see Differentials)

Procedures

• Findings on flexible sigmoidoscopy can provide the diagnosis of colitis.
• Findings on colonoscopy with biopsy confirm a diagnosis. Also, this is useful for documenting the extent of the disease, for monitoring disease activity, and for surveillance for dysplasia or cancer; however, be cautious in attempting colonoscopy with biopsy in a patient with severe disease because of the possible risk of perforation or other complications.
• The extent of disease is defined by the following:
• • Extensive disease - Evidence of ulcerative colitis proximal to the splenic flexure
  • Left-sided disease - Ulcerative colitis present in the descending colon up to, but not proximal to, the splenic flexure
  • Proctosigmoiditis - Disease limited to the rectum with or without sigmoid involvement

Histologic Findings

Endoscopically, ulcerative colitis is characterized by a uniform inflammatory reaction limited to the colon by extending from the rectum without intervening areas of normal mucosa to part or all of the colon.

Histologically, most of the pathology is limited to the mucosa and submucosa.  In fulminant cases, the muscularis propria can be affected. Pathologic features that are typically seen include intense infiltration of the mucosa and submucosa with neutrophils and crypt abscesses, lamina propria with lymphoid aggregates, plasma cells, mast cells and eosinophils, and shortening and branching of the crypts. These features are not unique to ulcerative colitis. Except for crypt distortion, the cellular response can be in acute infectious colitis or Crohn disease.

TREATMENT

Section 6 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical Care

An appropriate medical regimen for ulcerative colitis is determined by the severity and the extent of disease. See Medication. 

Prior to initiating therapy, an accurate assessment is needed; this assessment should include a thorough history and physical examination. A colonoscopy is preferable.

See related CME at Advances in Ulcerative Colitis.

Surgical Care

Considerations for total colectomy are as follows:

• Refractory disease with failure to medical therapy
• Evidence of carcinoma or dysplasia
• Severe hemorrhage
• Fulminant colitis not responsive to treatment
• Toxic megacolon
• Perforation (free or walled-off)
• Obstruction and stricture with suspicion for cancer
• Systemic complications from medications, particularly steroids
• Failure to thrive in children

Consultations

• Gastroenterologist
• Consultation with a surgeon for severe or fulminant colitis

Diet

• No specific diet restrictions are required for patients with ulcerative colitis. However, many patients with ulcerative colitis can have concurrent lactose intolerance.
• No specific diet can maintain remission.
• Elemental nutrition and parenteral nutrition have no primary therapeutic role in ulcerative colitis, although parenteral nutrition is often used in patients who are severely ill as effective nutritional support.

MEDICATION

Section 7 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

Drug Category: Tumor necrosis factor (TNF) inhibitors

These agents prevent the endogenous cytokine from binding to cell surface receptor and exerting biological activity.

Drug Category: Immunomodulators

These agents regulate key factors of the immune system.

Drug Category: Antimicrobials

Antibiotics have not been shown to provide consistent benefits from several controlled trials for the treatment of active ulcerative colitis. Thus, they are usually administered on an empiric basis in patients with severe colitis in whom they may help with averting a life-threatening infection. They have been shown to be effective for the treatment of pouchitis after ileoanal pouch anastomosis procedure.

Drug Category: Corticosteroids

Used in moderate-to-severe active cases for induction of remission. They have no benefit in maintaining remission; long-term use can cause adverse effects.

Drug Category: 5-aminosalicylic Acid Derivative

These agents have anti-inflammatory effects.

FOLLOW-UP

Section 8 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Further Outpatient Care

• A screening colonoscopy is recommended for all patients with ulcerative colitis 8-10 years after the onset of symptoms to rule out colonic neoplasia and to reclassify the extent of disease.
• Patients with extensive colitis or left-sided colitis with negative findings on screening colonoscopy should begin surveillance colonoscopy in 1-2 years.
• For patients with ulcerative colitis and primary sclerosing cholangitis, screening and subsequent surveillance colonoscopy begin on an annual basis at the time of onset of primary sclerosing cholangitis.
• Patients with proctosigmoiditis have no increased risk for colorectal cancer compared with the general population. However, these patients should be managed according to the current guidelines on colorectal cancer screening. See related CME at Guidelines Issued for Early Detection of Colorectal Cancer.
• If high-grade dysplasia or cancer is found, colectomy is performed. 
• The management of low-grade dysplasia is controversial; however, most experts would recommend colectomy.

Complications

• Toxic megacolon occurs in less than 2% of cases and can be induced by hypokalemia, opiates, anticholinergics, and barium enemas. Patients are acutely ill. Conservative treatment can be tried for 24-48 hours with IV fluids, IV steroids, antibiotics, and IV cyclosporine. Patients may eventually require a total colectomy.
• The risk of colorectal cancer increases by 0.5-1% per year. Regular surveillance is needed.

Prognosis

• Most cases are controlled with medical therapies, with the patient experiencing lifelong exacerbations and remissions. In more severe cases, surgery results in a cure.

Patient Education

• For excellent patient education resources, visit eMedicine's Crohn Disease Center and Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education articles Inflammatory Bowel Disease, Crohn Disease, and Crohn Disease FAQs. 
• Additional information can be found at Crohn's & Colitis Foundation of America (CCFA). 

MISCELLANEOUS

Section 9 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical/Legal Pitfalls

• Colonoscopy performed in patients with severely active disease can cause significant complications, such as perforation or toxic megacolon.
• Barium enemas performed in severe cases can precipitate toxic megacolon.
• Adverse effects due to medical therapy can be frequent; therefore, routine laboratory monitoring should be followed.
• Screening colonoscopy with subsequent surveillance colonoscopy should be initiated 8-10 years after the onset of symptoms of ulcerative colitis.

Special Concerns

• Pregnancy
• Sclerosing cholangitis and cholangiocarcinoma
• Extracolonic manifestations

MULTIMEDIA

Section 10 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Media file 1:  Ulcerative colitis as visualized with a colonoscope.
	View Full Size Image
Media type:  Photo

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

• Alcalde Encinas MM, Perez-Gracia A, Hallal H, et al. [Cerebral venous sinus thrombosis and ulcerative colitis]. Rev Esp Enferm Dig. Feb 2000;92(2):105-8. [Medline].
• Brown MO. Inflammatory bowel disease. Prim Care. Mar 1999;26(1):141-70. [Medline].
• Fichera A, Michelassi F. Indication for surgery: a surgeon's opinion. In: Sartor RB, Sandborn WJ. Kirsner's Inflammatory Bowel Diseases. 6^th ed. New York: Saunders; 2004:596-601/39.
• Froehlich F, Larequi-Lauber T, Gonvers JJ, et al. 11. Appropriateness of colonoscopy: inflammatory bowel disease. Endoscopy. Oct 1999;31(8):647-53. [Medline].
• Hanauer SB. Inflammatory bowel disease. N Engl J Med. Mar 28 1996;334(13):841-8. [Medline].
• Itzkowitz SH, Present DH. Consensus conference: Colorectal cancer screening and surveillance in inflammatory bowel disease. Inflamm Bowel Dis. Mar 2005;11(3):314-21. [Medline].
• Jayanthi V, Probert CS, Mayberry JF. Epidemiology of inflammatory bowel disease. Q J Med. Jan 1991;78(285):5-12. [Medline].
• Kamm MA, Sandborn WJ, Gassull M, et al. Once-daily, high-concentration MMX mesalamine in active ulcerative colitis. Gastroenterology. Jan 2007;132(1):66-75; quiz 432-3. [Medline].
• Kornbluth A, Sachar DB. Ulcerative colitis practice guidelines in adults (update): American College of Gastroenterology, Practice Parameters Committee. Am J Gastroenterol. Jul 2004;99(7):1371-85. [Medline].
• Lichtenstein GR, Abreu MT, Cohen R, et al. American Gastroenterological Association Institute technical review on corticosteroids, immunomodulators, and infliximab in inflammatory bowel disease. Gastroenterology. Mar 2006;130(3):940-87. [Medline].
• Rioux JD, Silverberg MS, Daly MJ, et al. Genomewide search in Canadian families with inflammatory bowel disease reveals two novel susceptibility loci. Am J Hum Genet. Jun 2000;66(6):1863-70. [Medline].
• Stenson WF, Korzenik J. Inflammatory bowel disease. In: Yamada T, ed. Textbook Of Gastroenterology. Vol 2. 4^th ed. Philadephia: Lippincott Williams & Wilkins; 2003:1699-1759.
• Thomas GA, Rhodes J, Green JT. Role of smoking in inflammatory bowel disease: implications for therapy. Postgrad Med J. May 2000;76(895):273-9. [Medline].
• Tremaine WJ. Collagenous colitis and lymphocytic colitis. J Clin Gastroenterol. Apr 2000;30(3):245-9. [Medline].

Article Last Updated: Aug 7, 2008