Ungaro R, Mehandru S, Allen PB, Peyrin-Biroulet L, Colombel JF. Ulcerative colitis. Lancet. 2017;389(10080):1756-1770. doi:10.1016/S0140-6736(16)32126-2
Surprisingly, in my FM rotation I’ve encountered quite a few GI bleeders whose lower GI bleed was not explained by any particular diagnoses at the time
Since UC is a diagnosis of exclusion, I decided to take a deeper dive on the topic.
- Ulcerative colitis is a chronic, idiopathic inflammatory disease that affects the colon, most commonly affecting adults aged 30–40 years and resulting in disability. It is characterized by relapsing and remitting mucosal inflammation, starting in the rectum and extending to proximal segments of the colon. The aim of therapy is to induce and maintain clinical and endoscopic remission. Aminosalicylates are the main choice of treatment for mild to moderate ulcerative colitis, topical and systemic steroids can be used to treat ulcerative colitis flares, while immunosuppressants and biological drugs are used in moderate to severe disease. Colectomy is needed in up to 15% of patients with ulcerative colitis. The annual direct and indirect costs related to ulcerative colitis are estimated to be as high as US$8.1–14.9 billion in the USA.
- The rising incidence of ulcerative colitis worldwide suggests the importance of environmental factors in its development. Former cigarette smoking is one of the strongest risk factors associated with ulcerative colitis while active smokers are less likely to develop ulcerative colitis compared with former and non-smokers and have a milder disease course. Appendectomy appears to confer a protective effect against developing ulcerative colitis, especially when done for acute appendicitis in young patients.
- Patients with ulcerative colitis usually present with diarrhea, which may be associated with blood. Bowel movements are frequent and small in volume as a result of rectal inflammation. Associated symptoms include colicky abdominal pain, urgency, tenesmus, and incontinence. Patients with mainly distal disease may have constipation accompanied by frequent discharge of blood and mucus.
- Patients may have systemic symptoms including fever, fatigue, and weight loss. Patients may also have dyspnea and palpitations due to anemia secondary to iron deficiency from blood loss, anemia of chronic disease, autoimmune hemolytic anemia, leukocytosis, or thrombocytosis.
- The diagnosis of ulcerative colitis is based on a combination of symptoms, endoscopic findings, histology, and the absence of alternative diagnoses. All patients with possible ulcerative colitis should have stool assessments (stool culture and Clostridium difficile assay) to rule out enteric superimposed infections, especially since US patients commonly have dysbiosis.
- Determining the severity and extent of ulcerative colitis is important for selecting the most appropriate treatment. Disease severity is typically classified as remission, mild, moderate, or severe.
- Age of onset appears to affect the disease course, since patients with disease onset after age 60 years tend to have milder disease compared with younger patients.
- First-line therapy in mild to moderate disease is the 5-ASA (aminosalycilate) drugs, which can be administered as suppositories, enemas, or oral formulations. Choice of a form of administration is guided by the proximity of disease extent.
- Patients who do not respond or do not achieve remission on 5-ASA drugs can be treated with corticosteroids.
- Topical 5-ASA is superior to topical corticosteroids at inducing remission
- Patients with moderate to severe colitis should be managed with thiopurines or biological drugs, or both (figure 5). Thiopurines (azathioprine or 6-mercaptopurine) can be used in patients with steroid-dependent moderate to severe disease to maintain remission.
- Anti-TNF-α drugs, such as infliximab, adalimumab, and golimumab, are effective at inducing and maintaining remission in moderate to severe disease
Acute & severe UC
- Patients with acute severe ulcerative colitis, defined as six or more bloody bowel movements per day and at least one of the following: pulse rate >90 beats per min, temperature >37.8°C, hemoglobin count <10.5 g/dL, or ESR >30 mm/h, should be admitted to a tertiary care center. Acute severe ulcerative colitis is associated with significant morbidity and mortality of approximately 1%. Patients are initially treated with intravenous corticosteroids to which approximately 65% will respond.
- Absolute indications for surgery include uncontrolled hemorrhage, perforation, and colorectal carcinoma or dysplastic lesions not amenable to endoscopic removal. Surgery is also indicated in refractory acute severe ulcerative colitis or medically refractory disease. The most commonly performed surgery for ulcerative colitis is restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). When surgery is emergent or urgent, it is typically done in two or three stages starting with a subtotal colectomy and creation of a temporary ileostomy (first stage) to decrease the risk of immediate postoperative complications such as anastomotic leak or pelvic sepsis. The ileal pouch is then created and anastomosed to the anal canal with a diverting ileostomy (second stage), which is eventually taken down to restore intestinal continuity (third stage).
- When patients have symptoms suggestive of an ulcerative colitis flare, infection should be excluded and objective assessments, such as sigmoidoscopy, fecal calprotectin, or stool lactoferrin should be done. Fecal calprotectin appears to have the highest sensitivity and specificity for active inflammation.
- The major elements of chronic care for patients with ulcerative colitis are colon cancer surveillance and health maintenance. Patients with ulcerative colitis should undergo regular surveillance colonoscopy to detect dysplasia and early cancer.