Jill C. Cash and Cheryl A. Glass
Definition
A.Ulcerative colitis (UC) is one of the two inflammatory bowel diseases (IBDs), along with Crohn’s disease (CD). UC is limited to the colon; it extends proximally from the anal verge in an uninterrupted pattern to a part of or the entire colon. Extracolonic manifestations also include uveitis, pyoderma gangrenosum, pleuritis erythema nodosum, ankylosing spondylitis, and spondyloarthropathies. Refer to Table 14.27 for the definition of severity of UC.
B.Neither UC nor CD should be confused with irritable bowel Disease (IBD) , which affects the motility of the colon. Smoking is negatively associated with UC; the relationship is reversed in CD. The general course of UC is intermittent exacerbations and remissions. In severe cases, surgery may be required. The choice of treatment depends on disease activity and extent of pathology, patient acceptability, and mode of drug delivery.
TABLE 14.27 Definition of Severity of Ulcerative Colitis
a Acute severe colitis is defined by Truelove and Witts Criteria (1955).
ESR, erythrocytic sedimentation rate; UC, Ulcerative colitis.
Source: Adapted from Truelove, S. C. & Witts, L. J. (1955). Cortisone in ulcerative colitis; final report on a therapeutic trial. British Medical Journal 2(4947), 1041–1048.
C.Histologically, most of the pathology of UC is limited to the mucosa and submucosa. The severity of UC is defined by the following:
1.Pan-ulcerative (total colitis): Extensive disease with evidence of UC proximal to the splenic flexure. Massive dilation of the colon (toxic megacolon) may lead to bowel perforation.
2.Left-sided disease: Continuous UC that is present from the rectum, the descending colon up to, but not proximal to, the splenic flexure
3.Proctosigmoiditis: Disease is limited to the rectum and sigmoid colon involvement.
4.Ulcerative proctitis: Disease is limited to the rectum—usually less than the full rectum.
D.In 2015, the Toronto Consensus Clinical Practice Guidelines for the Management of Nonhospitalized UC published 34 recommendations, including statements on 5-aminosalicylates (5-ASA) corticosteroids, immunosuppressants, anti-tumor necrosis factor (TNF) therapy, and other agents, including probiotics. The guidelines are available at www.gastrojournal.org/article/S0016-5085(15)00303-0/abstract.
E.The 2015 Toronto Consensus guideline defined remission and response with UC as:
1.Complete remission: Both symptomatic remission and endoscopic healing defined as follows:
a.Endoscopic healing: Normal mucosa, vascular blurring, or chronic changes (e.g., inflammatory polyps, scarring) without friability.
b.Symptomatic remission: Normal stool frequency (≤3/d) and no blood in the stool.
2.Symptomatic response: Meaningful improvement in symptoms as judged by both the patient and physician in the absence of remission; response should not be considered a desirable final outcome but is useful to assess early response to treatment.
Incidence
A.The annual incidence of UC is 10.4 to 12 per 100,000, depending on the country.
B.UC is three times more common than CD.
C.The most common cause of death in patients with UC is toxic megacolon.
D.Adenocarcinoma of the colon develops in 3% to 5 % of patients with UC; the risk increases with the duration of the disease.
E.Approximately 6.2% of patients with IBD have a major extraintestinal manifestation..
1.Uveitis is the most common—3.8%.
2.Primary sclerosing cholangitis—3%.
3.Ankylosing spondylitis—2.7%.
4.Erythema nodosum—1.9%.
5.Pyoderma gangrenosum—1.2%.
Pathogenesis
A.Exact etiology is unknown.
B.UC may be considered an autoimmune disease. Persons with UC often have p-antineutrophil cytoplasmic antibodies (p-ANCAs). Abnormalities of humoral and cell-mediated immunity and/or generalized enhanced reactivity against intestinal bacterial antigen may also be causes of UC.
Predisposing Factors
A.Caucasian.
B.Jewish descent.
C.30% more females than males.
D.Genetic susceptibility (chromosomes 12 and 16).
Common Complaints
A.Frequent small-volume diarrhea.
B.Bloody diarrhea with or without mucus.
C.Severe bowel urgency.
D.Abdominal cramps and pain with bowel movement (BM).
E.Constipation.
F.Anorexia.
G.Anemia.
H.Nocturnal BMs.
Other Signs and Symptoms
A.Tenesmus (rectal urgency/constant feeling of need to pass stool).
B.Abdominal tenderness.
C.Arthralgias.
D.Fatigue secondary to anemia.
E.Severe UC:
1.Fever.
2.Tachycardia.
3.Significant abdominal tenderness.
4.Signs of volume depletion.
Subjective Data
A.Review the onset, duration, signs, and symptoms (number of stools, presence/absence of blood in the stool, fever, and abdominal pain).
B.Review the patient’s recent travel history or camping for the presence of intestinal infection.
C.Review the patient’s medication history, including antiboitics and nonsteroidal anti-inflammatory drugs (NSAIDs). One third of patients with exacerbation of UC report recent NSAID use.
D.Review family history for IBD, celiac disease, and colorectal cancer.
E.Review the patient’s smoking status.
F.Review the patient’s history or contact related to tuberculosis (TB; testing required prior to biologic therapy).
G.Evaluate if the patient has symptoms of uveitis including light sensitivity, floaters, blurry vision, or pain/tenderness to touch.
Physical Examination
A.Check temperature (if indicated), pulse, and blood pressure. Measure height and weight to calculate body mass index (BMI). Follow serial weights.
B.Inspection:
1.Observe the general overall appearance for nutritional status, cachexia, and pallor.
2.Observe the perianal region for the presence of tags, fissures, fistulas, and abscess.
3.Observe the abdomen for distension and presence of surgical scars.
4.Eye examination for redness, irritation, and ocular complications (episcleritis, scleritis, and uveitis).
5.Evaluate for the presence of dermatological findings, including erythema nodosum and pyoderma gangrenosum.
C.Auscultation:
1.Auscultate the heart and lungs.
2.Auscultate all four quadrants of the abdomen.
D.Palpation:
1.Palpate all four quadrants of the abdomen, observing for tenderness, rebound, and guarding.
2.Evaluate the presence of hepatomegaly.
3.Evaluate the joints for tenderness, warmth, swelling, and effusion.
4.Perform digital rectal examination to assess for anal strictures and rectal masses.
Diagnostic Tests
A.Diagnosis is best made with endoscopy and biopsy.
B.Laboratory tests:
1.Complete blood count (CBC) with electrolytes.
2.Platelet count.
3.Erythrocyte sedimentation rate (ESR).
4.C-reactive protein (CRP).
5.Cytomegalovirus (CMV): chronic immunosuppressive steroids.
6.HIV.
C.Stool testing:
1.Evaluate bacterial, viral, or parasitic causes of diarrhea.
2.Occult blood.
3.Fecal leukocytes.
D.Plain abdominal radiograph.
E.CT scan.
F.MRI.
G.Ultrasound.
H.Double-contrast barium enema.
I.Celiac antibody testing should be considered.
J.Intestinal TB testing should be considered.
Differential Diagnoses
A.UC.
B.Ischemic colitis (especially in the elderly).
C.Toxic megacolon.
D.Colon cancer.
E.Adenocarcinoma.
F.Rectal cancer.
G.Radiation colitis.
H.Intestinal infections.
I.Intestinal lymphoma.
J.Chronic diverticulitis.
K.Amebiasis.
Plan
A.General interventions:
1.Severe UC should be managed jointly by a gastroenterologist in conjunction with a colorectal surgeon.
2.Stress reduction and stress management may improve symptoms.
3.Pretreatment screening for TB, using Mantoux (a PPD) skin testing, is needed before initiation of immunomodulators and thiopurines.
4.Immunization status:
a.Immunizations with inactivated vaccine should be brought up to date and rigorously maintained during treatment, including influenza, meningococcus, and pneumococcus.
b.Check varicella titers prior to treatment with immunomodulators and reimmunize if titers are low.
c.The risk of administering live vaccines (polio, rubella, and yellow fever) to patients on immunomodulators has not been established; however, most experts avoid live vaccines during treatment.
B. 
See Section III: Patient Teaching Guide Crohn’s Disease and Ulcerative Colitis.
C.Dietary management:
1.Adequate nutrition is critical to promotion of healing. Sufficient protein and calories limit the stress on an inflamed bowel.
2.Many patients with UC have concurrent lactose intolerance (see Appendix B for lactose-intolerance dietary recommendations).
3.Decrease dietary fiber during increased disease activity.
4.Low-residue diet may decrease the frequency of BMs.
5.High-residue diet may be helpful in ulcerative proctitis when constipation is the dominant symptom.
6.Vitamin and nutritional supplements may be recommended.
D.See Section III: Patient Teaching Guide Nicotine Dependence.
E.Pharmacologic treatment. Refer to the American College of Gastroenterology Practice Guidelines for full treatment algorithms at http://s3.gi.org/physicians/guidelines/UlcerativeColitis.pdf or the 2015 Toronto Consensus Guidelines for the Management of UC algorithms: