Ulcerative Colitis

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Chapter 60 Ulcerative Colitis

INTRODUCTION

Description: Ulcerative colitis is an inflammatory bowel disease characterized by an inflammation limited to the mucosa of the large bowel and found primarily in the descending colon and rectum (although the entire colon may be involved). The disease is characterized by intermittent bouts of symptoms interspersed by periods of quiescence.
Prevalence: Seventy to 150 in 100,000.
Predominant Age: 20 to 50 years, 20% of patients are younger than 21. (Usually starts between the ages of 15 and 30, and less frequently between 50 and 70 years of age).
Genetics: Family history present in up to 20% (ulcerative colitis or Crohn disease). More common in some ethnic groups (e.g., Jews).

ETIOLOGY AND PATHOGENESIS

Causes: An inflammatory process limited to the mucosa of the large bowel and found primarily in the descending colon and rectum, although the entire colon may be involved. Genetic, infectious, immunologic, and psychologic factors have been postulated to underlie the process.
Risk Factors: Family history. Negatively related to smoking.

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Abdominal pain (generally mild to moderate; the pain is frequently relieved by a bowel movement, but many report the sensation of incomplete evacuation)
• Diarrhea (voluminous, watery, with occasional blood)
• Fever and weight loss
• Arthralgias and arthritis (15% to 20%)
• Aphthous ulcers of the mouth (5% to 10%)

DIAGNOSTIC APPROACH

Differential Diagnosis

• Irritable bowel syndrome (IBS; ulcerative colitis may be differentiated from irritable bowel syndrome by the frequent presence of fever or bloody stools in ulcerative colitis)
• Crohn disease
• Hemorrhoids
• Colon carcinoma
• Diverticulitis
• Infectious diarrhea (Escherichia coli, Salmonella, Shigella, Entamoeba histolytica)
• Iatrogenic (antibiotic associated)
• Radiation proctitis/colitis

Associated Conditions: Ocular complications (uveitis, cataracts, keratopathy, corneal ulceration, retinopathy; 4% to 10% of patients), liver and biliary complications (cirrhosis, 1% to 5%; sclerosing cholangitis, 1% to 4%; bile-duct carcinoma), ankylosing spondylitis, and osteoporosis.

Workup and Evaluation

Laboratory: No specific evaluation indicated. Complete blood count to evaluate blood loss or inflammation. Albumen and potassium levels may be reduced or liver functions test results may be elevated.
Imaging: Barium enema (air contrast).
Special Tests: Sigmoidoscopy, colonoscopy, or rectal biopsy.
Diagnostic Procedures: History, sigmoidoscopy, barium enema, or rectal biopsy.

Pathologic Findings

Superficial inflammation with ulceration is common. Hyperemia and hemorrhage also are common. The rectum is involved in 95% of cases, but the inflammation extends proximally in a continuous manner, at times even involving the terminal ileum.

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Evaluation and control of inflammation, prevention of complications, maintenance of nutrition (including adequate iron intake).
Specific Measures: Severe exacerbations may require hospitalization. Patients whose disease is refractory to antibiotic therapy may require surgical resection. (Between 25% and 40% of patients with ulcerative colitis eventually undergo colectomy because of massive bleeding, severe illness, rupture of the colon, or risk of cancer.)
Diet: No specific dietary changes indicated except for those based on other indications (such as lactose intolerance).
Activity: No restriction.

Drug(s) of Choice

Sulfasalazine 1 to 4 g PO daily (useful for both mild flare-ups and chronic suppression; approximately 10% of patients require chronic suppressive therapy).
Steroid enemas or mesalamine (5-aminosalicylic acid [5-ASA]) enemas or suppositories.
Prednisone 40 to 60 mg PO daily for flare-ups (tapered off over 2 months).
Contraindications: Known or suspected allergy or intolerance.
Precautions: Antidiarrheal agents may precipitate toxic megacolon.
Interactions: See individual agents.

Alternative Drugs

Azathioprine and 6-mercapto-purine (6-MP) may be used for patients who have not responded to 5-ASAs or corticosteroids or who are dependent on corticosteroids. Other oral 5-ASA derivatives are being studied. Antidiarrheal agents (diphenoxylate-atropine and loperamide) may be used but may precipitate toxic megacolon. Preliminary studies with Tetomilast (OPC-6535), a novel thiazole compound, failed to achieve statistically significant effects, but trends suggest possible utility.

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FOLLOW-UP

Patient Monitoring: Normal health maintenance, periodic follow-up to monitor status of disease and possible complications. Colonoscopy to watch for the possible development of cancer should be performed every 1 to 2 years beginning 7 to 8 years after the onset of disease. Annual testing of liver function is desirable.
Prevention/Avoidance: None (prevention of complications as previously mentioned).
Possible Complications: Perforation, toxic megacolon, hepatic disease, bowel stricture and obstruction, colon cancer (30% after 25 years, less for left-sided disease). Mortality for initial attack is approximately 5%.
Expected Outcome: Highly variable; 75% to 85% of patients experience relapses, 20% require colectomy. Colon cancer risk is the greatest factor affecting long-term prognosis and management.

MISCELLANEOUS

Pregnancy Considerations: No effect on pregnancy. Of patients with inactive disease, 30% have relapses during pregnancy, 15% in the first trimester. Treatment with sulfasalazine does not affect the outcome of the pregnancy. It is recommended that pregnancy be delayed until the disease is in remission.
ICD-9-CM Codes: 556.9.

REFERENCES

Level I

Ardizzone S, Maconi G, Russo A, et al. Randomised controlled trial of azathioprine and 5-aminosalicylic acid for treatment of steroid dependent ulcerative colitis. Gut. 2006;55:47. Epub 2005 Jun 21

Level II

Rutgeerts P, Sandborn WJ, Feagan BG, et al. Infliximab for induction and maintenance therapy for ulcerative colitis. N Engl J Med. 2005;353:2462.

van Staa TP, Card T, Logan RF, Leufkens HG. 5-Aminosalicylate use and colorectal cancer risk in inflammatory bowel disease: a large epidemiological study. Gut. 2005;54:1573. Epub 2005 Jun 30

Level III

Cima RR, Pemberton JH. Medical and surgical management of chronic ulcerative colitis. Arch Surg. 2005;140:300.

Hannauer SB. Inflammatory bowel disease. N Engl J Med. 1996;334:841.

Rapkin AJ, Mayer EA. Gastroenterologic causes of chronic pelvic pain. Obstet Gynecol Clin North Am. 1993;20:663.

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Chapter 60 Ulcerative Colitis

INTRODUCTION

Description: Ulcerative colitis is an inflammatory bowel disease characterized by an inflammation limited to the mucosa of the large bowel and found primarily in the descending colon and rectum (although the entire colon may be involved). The disease is characterized by intermittent bouts of symptoms interspersed by periods of quiescence.
Prevalence: Seventy to 150 in 100,000.
Predominant Age: 20 to 50 years, 20% of patients are younger than 21. (Usually starts between the ages of 15 and 30, and less frequently between 50 and 70 years of age).
Genetics: Family history present in up to 20% (ulcerative colitis or Crohn disease). More common in some ethnic groups (e.g., Jews).

ETIOLOGY AND PATHOGENESIS

Causes: An inflammatory process limited to the mucosa of the large bowel and found primarily in the descending colon and rectum, although the entire colon may be involved. Genetic, infectious, immunologic, and psychologic factors have been postulated to underlie the process.
Risk Factors: Family history. Negatively related to smoking.

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Abdominal pain (generally mild to moderate; the pain is frequently relieved by a bowel movement, but many report the sensation of incomplete evacuation)
• Diarrhea (voluminous, watery, with occasional blood)
• Fever and weight loss
• Arthralgias and arthritis (15% to 20%)
• Aphthous ulcers of the mouth (5% to 10%)

DIAGNOSTIC APPROACH

Differential Diagnosis

• Irritable bowel syndrome (IBS; ulcerative colitis may be differentiated from irritable bowel syndrome by the frequent presence of fever or bloody stools in ulcerative colitis)
• Crohn disease
• Hemorrhoids
• Colon carcinoma
• Diverticulitis
• Infectious diarrhea (Escherichia coli, Salmonella, Shigella, Entamoeba histolytica)
• Iatrogenic (antibiotic associated)
• Radiation proctitis/colitis

Associated Conditions:

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