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ULCERRATIVE COLITIS. PROF. WU SHUMING. Ulcerative Colitis.

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Ulcerrative colitis

ULCERRATIVE COLITIS

PROF. WU SHUMING


Ulcerative colitis
Ulcerative Colitis

  • Ulcerative colitis is a chronic disorder of still unknown aetiology, characterized by inflammation limited to the colonic mucosa, and by an intermittent, relapsing clinical course. It has a prevalence of almost 100 in 10,0000 in the West.


Epidemiology of inflammatory bowel disease
Epidemiology of Inflammatory Bowel Disease

FACTOR ULCERATIVE COLITIS

Incidence 2 - 10

Prevalence 35 - 100

Racial incidence High in caucasian

Ethnic indicence High in Jews

Gender Slight female

preponderance

Age at onset 15 - 25

? 55 - 65

Fewer smokers than

expected




Pathophysiology
pathophysiology Leong et al 2004

  • An immunologic mechanism in the pathogenesis is assumed, but the inciting causes are not known.

  • Hereditary factors: patients with ulcerative colitis have a 10-15% chance of having a first- or second-degree relative who also has one or the other type of inflammatory bowel disease.

  • intestinal inflammations : present with signs and symptoms similar to those of ulcerative colitis


Pathology
Pathology Leong et al 2004

It affects the rectum, and extends in continuity to involve a variable extent of the proximal colon, so that the patient may have proctitis alone, proctosigmoiditis, left-sided disease ( from the splenic flexure), or subtotal or total colitis. radiological grounds,


Total colitis may be associated with inflammation of the terminal ileum - known as backwash ileitis - if the ileocaecal valve is incompetent

backwash ileitis


Pathology1
Pathology terminal ileum - known as

  • In ulcerative colitis, the mucosal surface becomes irregular and granular. The mucosa is friable, meaning that it bleeds easily when touched. With more severe inflammation, bleeding may be spontaneous. In some patients with chronic ulcerative colitis, pseudopolyps develop.


Clinical presentation
clinical presentation terminal ileum - known as

The clinical presentation of ulcerative colitis depends on the length of colon involved and the severity of the episode. It is semiquantitatively classified by the presence or absence of systemic features such as pyrexia, tachycardia, anaemia; by the frequency of defaecation; and by the quantity of rectal blood loss. Bloody diarrhoea, often with tenesmus, is usual at presentation.


Signs and symptoms
Signs and symptoms. terminal ileum - known as

  • Patients with ulcerative colitis typically complain of bloody stool. If the inflammation is confined to the rectum, stools may be pure blood.


Signs and symptoms1
Signs and symptoms. terminal ileum - known as

  • Pallor due to anemia of blood loss or chronic disease may be evident.

  • Tachycardia may result from dehydration and diminished blood volume

  • Low-grade fever may be present.

  • Mild-to-moderate abdominal tenderness is characteristic of ulcerative colitis.

  • The rectal examination in patients with ulcerative colitis reveals bloody stool or frank blood,


Signs and symptoms2
Signs and symptoms. terminal ileum - known as

  • Growth retardation and failure to develop sexual maturity

    In fact, these complications may be the primary reason for the patient's consulting a physician. Growth failure is rarely caused by endocrine abnormalities but rather is a consequence of reduced caloric and nutritional intake or utilization. Treatment of the ulcerative colitis with attention to good nutrition, usually results in reestablishment of normal growth and development.


Signs and symptoms3
Signs and symptoms. terminal ileum - known as

  • Abdominal distention, rebound tenderness, absence of bowel sounds, and high fever suggest toxic megacolon


Clinical course of uc
Clinical Course of UC terminal ileum - known as

NUMBER OF PATIENTS PERCENTAGE

Acute fulminating 20 8.0

Chronic intermittent 161 64.4

Chronic continuous 18 7.2

One attack only 45 18.0

Total colectomy in first attack 2 0.8

Died in first attack of other causes 1 0.4

Unknown 2 0.8

Total 249 100.0


Onset and course of symptoms
Onset and course of symptoms. terminal ileum - known as

  • Ulcerative colitis typically begin in childhood or early adulthood, although ulcerative colitis may develop in patients of any age.

  • Most patients with ulcerative colitis experience intermittent exacerbations with nearly complete remissions between attacks.

  • In ulcerative colitis, about 5-10% of patients have one attack without subsequent symptoms for decades.

  • A similar number have continuous symptoms, and some have a fulminating course requiring total proctocolectomy.


Complications of uc
Complications of UC terminal ileum - known as

  • Chronic ulcerative colitis predisposes to adenocarcinomaof the colon

  • toxic megacolon


Conditions that predispose to colon cancer
Conditions that predispose to colon cancer terminal ileum - known as

Advancing age

Family history of colorectal cancer or polyps

High-fat, low-fiber diet

Bowel disorders

Inflammatory bowel disease (ulcerative colitis, Crohn's

disease)

Adenomatous polyps

Some polyposis syndromes

Family cancer syndrome

Genital tract cancer in women


Toxic megacolon
Toxic Megacolon terminal ileum - known as

In severe colitis of any cause, the transverse colon may become dilated . When this finding is accompanied by fever, elevated white cell count, and abdominal tenderness, toxic megacolon is likely


Criteria for severe colitis
Criteria for Severe Colitis terminal ileum - known as

1.Diarrhea: 6 stools/per day or more with macroscopic blood

2.Fever: Mean evening temp.>37.5C or a temp. of >37.8C on at least 2 days out of 4.

3.Erythrocyte sedimentation rate elevation >30

4.Anemia: Hemoglobin level <115 g / liter

5.Tachycardia: Mean pulse rate > 90 /min

Truelove-Lancet 1974;1:1067


Colonoscopic mucosal features and their diagnostic specificity in ibd
Colonoscopic Mucosal Features and Their Diagnostic Specificity in IBD

LESION UC CD

Inflammation

Distribution

Colon

Contiguous +++ +

Symmetric +++ +

Rectum +++ +

Friability +++ +

Topography

Granularity +++ +

Cobblestoned + +++


Colonoscopic mucosal features and their diagnostic specificity inibd
Colonoscopic Mucosal Features and Their Diagnostic Specificity inIBD

LESION UC CD

Ulceration

Location

Overt colitis +++ +

Ileum 0 ++++

Discrete lesion + +++

Features

Size >1 cm + +++

Deep + ++

Linear + +++

Aphthoid 0 ++++

Bridging + ++


Ulcerative colitis versus crohn s disease
Ulcerative colitis versus Crohn's disease Specificity inIBD

Ulcerative colitis Crohn's disease

Pain crampy, lower abdominal, Pain constant, often in relieved by bowel movement right lower quadrant,

not relieved by bowel movement Bloody stool Stool usually not grossly bloody

No abdominal mass Abdominal mass, often in

right lower quadrant

Affects only colon May affect small and

large bowel, occasionally

esophagus and stomach

Mucosal disease (granulomas Transmural disease

are not a feature) (granulomas found in a

minority of patients)

Continuous from rectum May be discontinuous

(skip areas)


Differential diagnosis of ibd

Bacterial colitis Specificity inIBD

Campylobacter

Shigella

Salmonella

Escherichia coli (invasive)

Clostridium difficile--associated colitis

Parasitic colitis

Amebiasis

Schistosomiasis

Ischemic colitis

Radiation colitis

Behcet's colitis

Sexually transmitted colitis

Gonococcus

Chlamydia

Herpes

Trauma

Crohn's disease look-alikes

Lymphoma

Yersinia

Tuberculosis

* IBD = inflammatory bowel disease

Differential diagnosis of IBD


Laboratory test

a The CBC may document anemia and leukocytosis, Specificity inIBD

b. Stool studies. Stool samples should be examined for ova and parasites, cultured, and tested for C. difficile toxin.

c. Abdominal plain x-ray films.

d. Sigmoidoscopy. flexible instrument, The severity of the mucosal injury can be assessed, and other conditions in the differential diagnosis, such as Crohn's disease, ischemic colitis, and pseudomembranous colitis, may be implicated.

e. Colonoscopy and barium enema are contraindicated in severe colitis or toxic megacolon.

Laboratory Test


Extraintestinal manifestations of ibd
Extraintestinal manifestations of IBD* Specificity inIBD

Common to both ulcerative colitis and Crohn's disease

___________________________________

Area Condition Conditions related to Crohn's

Joints Peripheral arthritis Gallstones

Sacroiliitis Renal oxylate stones

Ankylosing spondylitis Vitamin B[12] deficiency

Obstructive hydronephrosis Skin Erythema nodosum

Pyoderma gangrenosum

Eyes Conjunctivitis

Iritis ,Episcleritis

Liver Fatty infiltration

Chronic active hepatitis

Pericholangitis

Sclerosing cholangitis

Bile duct carcinoma

Kidneys Pyelonephritis

Renal stones

General Amyloidosis* IBD = inflammatory bowel disease


Pyoderma gangrenosum Specificity inIBD



Sulfasalazine sasp
Sulfasalazine (SASP) Specificity inIBD

  • SASP: Two moieties of 5-aminosalicylic acid(5-ASA) and sulfapyridine(SP)

  • 20~30% is absorbed in SASP in upper GI, excreted from bile and urine

  • Intestinal bacteria break-down the other SASP into SP and 5-ASA

  • Absorbed lipophilic SP: side-effect

  • Poorly lipophilic remains in the colon


Adverse effects of sulfasazine

Dose related Specificity inIBD

nausea

vomiting

anorexia

folate mal-ab.

Headache

alopecia

Not dose related

skin rash

hemolytic anemia

agrannulocytosis

fibrosing alveolitis

hepatitis

male infertility

colitis

Adverse Effects of Sulfasazine


New salicylate drugs

MESALAZINE Specificity inIBD

PREPARATIONS

Enteric-coated Ctrl.-Released

Asacol Pentasa

Claversal

Salofalk

Rowasa

Prodrug

Osalazine

Balsalazide

Mesalazine

NEW SALICYLATE DRUGS


Mechanisms of steroid action ibd
Mechanisms of Steroid Action-IBD Specificity inIBD

  • Stabilizes lysosomal membranes

  • Reduces capillary permeability

  • Function as inhibitors of chemotaxis and phagocytosis

  • Impairs cell-mediated immunity in experimental models


Administration and dosage
Administration and Dosage Specificity inIBD

  • Oral

    Dosage

    Tapering

  • Intravenous

    Bolus or continuous infusion

  • Topical

    Position, Dosage, Duration


Ileorectal anastomosis Specificity inIBD

Brooke ileostomy


The End Specificity inIBD


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