Ulcerative Colitis

Epidemiology

• Prevalence 1:1000

• Age of onset 20-25 y; T incidence in Caucasians, especially Jews; familial in -10%

• Appendectomy prior to age 20 for appendicitis (N^M 2001:344:808) and tobacco use (NEJM

1987:316:707) have been reported to protect against the development of UC Pathology

• Extent: involves rectum (95%) and extends proximally and contiguously

50% of Pts have proctosigmoiditis. 30% left-sided colitis, and 20% pan-colitis

• Appearance: granular, friable mucosa with diffuse ulceration; pseudopolyps barium enema hazy margins (fine mucosal granularity), loss of haustra ("lead pipe")

• Microscopy: superficial inflammation + micro-ulcerations; crypt abscesses (PMNs)

Clinical manifestations

• Grossly bloody diarrhea, lower abdominal cramps, urgency, tenesmus

• Fulminant colitis (15%): progresses rapidly over 1-2 wks with I Hct, T ESR, fever, hypotension. >6 bloody BMs per day. distended abdomen with absent bowel sounds

erythema nodosum, pyoderma gangrenosum, aphthous ulcers, iritis, episcleritis, thromboembolic events, autoimmune hemolytic anemia seronegative arthritis, chronic hepatitis, cirrhosis, primary sclerosing cholangitis (PSC; with T risk of cholangiocarcinoma)

• Serologies: p-ANCA in 60-70% (associated with pancolitis and PSC)

Complications

• Toxic megacolon (5%): colon dilatation (^6 cm on KUB). colonic atony, systemic toxicity requires IV steroids and broad-spectrum abx; surgery if fails to improve w in 48-72 h

• Perforation • pneumoperitoneum, peritonitis

• Stricture (5%): occurs in rectosigmoid after repeated episodes of inflammation

• Colon cancer risk with pancolitis is greatest (7-16% cumulative risk at 20 y); Pts w left-sided colitis and PSC also at T risk: risk not increased with ulcerative proctitis

• Surveillance: yearly colonoscopy with random biopsies after 8 y of pancolitis or 15 y of left-sided colitis to look for dysplasia (low grade - 20% have cancer; high grade or dysplasia associated lesion mass (DALM) — r-40% have cancer) — colectomy if present

Prognosis

• Intermittent exacerbations in 80%; continual active disease in 10-15%; severe initial attack requiring urgent colectomy in 5-10%

• Mortality rate for severe attack of ulcerative colitis is <2%

• No difference in life expectancy compared to individuals without ulcerative colitis

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