Ulcerative Colitis

Endoscopic appearance of ulcerative colitis with significant ulceration with an irregular, friable, and erythematous, surface.

Endoscopic appearance of ulcerative colitis with significant ulceration with an irregular, friable, and erythematous, surface.

1) Disease severity can be classified using the Montreal Classification:

  • Mild: ESR normal, <4 stools per day, mild crampy abdominal pain, no systemic symptoms
  • Moderate: >4 stools daily, mild anemia, non-severe abdominal pain, no weight loss
  • Severe: > 6 stools per day + systemic toxicity (T >38, HR >90, Hgb <10, ESR >30)

2) Extraintestinal manifestations only occur in about 10% of patients and include:

  • MSK: anklyosing spondylitis, large joint arthritis, osteoporosis
  • Eye: uveitis and episcleritis
  • Skin: erythema nodosum and pyoderma gangrenosum
  • Heptobiliary: primary sclerosing cholangitis, fatty liver, autoimmune liver disease
  • Hematopoetic/coag: autoimmune hemolytic anemia, arterial and venous thromboembolism

3) Complications of UC include:

  • Acute: Bleeding 10%, fulminant colitis, toxic megacolon (>6cm colon or 9cm in cecum + systemic symptoms), perforation
  • Chronic: relapses, increased risk of colon cancer (start colonoscopy 8-10 years after sx onset and repeat every 1-2 years), strictures (due to chronic inflammation which can lead to obstruction)

4) Treatment: Induction begins with 5-ASA drugs or topical glucocorticoids for mild disease. Moderate to severe disease is treated with oral glucocorticoids (40-60mg prednisone daily).  If this fails or for severe disease, move on to IV steroids and possibly TNF inhibitors like infliximab or adalimumab. Maintainance for patients responding to steroids can include azathioprine or 6-mercaptoprine (check a TMPT level prior to starting as patients with low enzyme activity can develop drug toxicity!)