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Ulcerative Colitis

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🔥 Ulcerative colitis (UC) = a relapsing-remitting inflammatory disease of the colon, with continuous mucosal inflammation starting in the rectum. ⚠️ Risks: acute severe colitis (medical emergency) + ↑ risk of colorectal cancer.

📖 About

Chronic, relapsing-remitting inflammatory bowel disease (IBD) affecting colon & rectum only.
More common than Crohn’s disease. Incidence ~10–20/100,000; prevalence 50–100/100,000.
Classically in Caucasians & Jewish populations; peak onset 20–40 years.

🧬 Aetiology

Dysregulated immune response to gut flora + environment in genetically predisposed individuals.
⚡ Protective: smoking & prior appendicectomy.
🔎 Autoantibodies: pANCA often positive.
Common association: Primary Sclerosing Cholangitis (PSC).

🗺️ Extent of Disease

Always starts in the rectum (proctitis) and extends proximally in a continuous manner.

🩺 Clinical Presentation

💩 Bloody diarrhoea with mucus (may be 10–20/day in severe cases).
🚽 Urgency, tenesmus, incontinence.
🤒 Systemic features in severe disease: fever, tachycardia, weight loss.
⚡ Flares triggered by infections, NSAIDs, antibiotics, stress.

🌍 Extra-intestinal Features

🖐️ Skin: erythema nodosum, pyoderma gangrenosum.
👁️ Eyes: iritis, episcleritis.
🦴 Joints: arthritis, sacroiliitis.
🩺 Liver: PSC (strong link).
Other: mouth ulcers, clubbing, ↑ VTE risk, amyloidosis.

🧪 Pathology

Confined to colon & rectum; continuous pattern.
Mucosal-only inflammation (no transmural involvement).
Histology: goblet cell depletion, crypt abscesses, pseudopolyps.
Chronic disease: loss of haustra → “lead-pipe colon”, ↑ cancer risk.

📊 Assessing Severity (Modified Truelove & Witts’ Criteria)

Severity	Features
🙂 Mild	<4 bloody stools/day; no systemic upset; Hb >115; CRP <5
😐 Moderate	4–6 stools/day; mild systemic disturbance; Hb >105; CRP <30
😟 Severe	>6 bloody stools/day + systemic features (T >37.8, HR >90, Hb <105, CRP >30)
🚨 Fulminant	≥10 stools/day, continuous bleeding, severe toxicity, colonic dilatation on AXR

🔎 Investigations

🩸 Bloods: FBC (anaemia), CRP/ESR, U&E, LFTs, pANCA.
💩 Faecal calprotectin: raised in active inflammation.
📷 Imaging: – AXR: toxic megacolon (>6 cm), thumbprinting. – Sigmoidoscopy (preferred in flare): friable, erythematous mucosa. – Colonoscopy: for extent & surveillance (avoid in acute flare). – Barium enema (historical): lead-pipe colon, avoid in acute flare.

🔍 Comparison: Crohn’s Disease vs Ulcerative Colitis

Feature	🌱 Crohn’s Disease	🔥 Ulcerative Colitis
Distribution	Anywhere mouth → anus, most often terminal ileum; skip lesions	Starts in rectum, continuous spread proximally through colon
Depth of Inflammation	Transmural (full thickness)	Mucosa + submucosa only
Histology	Non-caseating granulomas, fissures	Crypt abscesses, mucosal ulceration, no granulomas
Appearance	“Cobblestone” mucosa, thick bowel wall, strictures, fistulas	Red, raw, friable mucosa, pseudopolyps
Symptoms	RLQ pain, weight loss, diarrhoea (± blood), perianal disease	Bloody diarrhoea, urgency, tenesmus, LLQ pain
Smoking	🚬 Risk factor (worsens disease)	🚭 Protective (symptoms often worse in ex-smokers)
Extra-intestinal	More renal stones (oxalate), gallstones, B12 deficiency	PSC (primary sclerosing cholangitis), ↑ colorectal cancer risk
Fistula/Stricture	✅ Common (entero-enteric, perianal, entero-vesical)	❌ Rare
Surgery	Not curative (recurs in new bowel segments)	Curative (colectomy removes disease)
Cancer risk	Increased with colonic involvement	High with long-standing pancolitis or PSC

💡 Teaching Tip: In exams, remember the mnemonic:

Crohn’s → Cobblestone, Complete wall (transmural), Complications (fistulae/strictures)
UC → starts in Ulcerated rectum, continuous, mucosal only, curable with colectomy.

💊 Management (Step-Up)

Step	Treatment
1	5-ASA (Mesalazine, Sulfasalazine) ± rectal 5-ASA for distal disease
2	Rectal steroids
3	Oral steroids (Prednisolone 40–60 mg, tapered)
4	IV steroids (Hydrocortisone, Methylprednisolone)
5	Immunomodulators (Azathioprine, 6-Mercaptopurine)
6	Biologics (Infliximab, Vedolizumab) or IV Ciclosporin
7	Surgery (panproctocolectomy + ileoanal pouch)

⚠️ Acute Severe UC

Admit + IV fluids, IV hydrocortisone, nutritional support, VTE prophylaxis.
Monitor stool frequency, vitals, bloods, AXR daily.
If no response in 3–5 days → Rescue therapy (Ciclosporin / Infliximab) or Surgery.
🚨 Toxic megacolon: urgent surgical input (colectomy if deterioration).

🔪 Surgical Options

Panproctocolectomy + ileal pouch-anal anastomosis → curative, ↓ cancer risk, but ↑ stool frequency, pouchitis risk.

📦 Other Treatment Options

🛡️ Immunosuppressants: Azathioprine, Mercaptopurine (monitor FBC closely).
💉 Biologics: Infliximab, Vedolizumab for refractory disease.
💊 Ciclosporin: Acute rescue therapy if steroids fail.

🌱 Supportive Care

Dietitian input → nutritional optimisation.
IBD nurse specialist → flare-up support, medication counselling.

💡 Teaching Pearls:
– UC = continuous, mucosal-only inflammation starting at rectum (vs Crohn’s = skip lesions, transmural).
– Acute severe colitis = emergency: IV steroids first, colectomy if no response.
– Long-term risk: colorectal cancer → surveillance colonoscopy.
– Extra-intestinal features (skin, eyes, joints, liver) often parallel disease activity.

📚 References

NICE Guideline – Ulcerative Colitis

Cases — Ulcerative Colitis (UC)

Case 1 (Mild–moderate flare): 👨‍🦱 A 27-year-old man presents with 6 weeks of bloody diarrhoea, urgency, and tenesmus. Flexible sigmoidoscopy shows continuous inflammation from the rectum to the sigmoid colon. Management: Oral mesalazine (5-ASA) started, with rectal mesalazine enemas. Corticosteroids reserved if symptoms fail to settle. Outcome: Good response to therapy. Patient counselled on smoking cessation and regular surveillance colonoscopy for cancer risk.
Case 2 (Severe acute colitis): ⚡ A 34-year-old woman with known UC presents with >10 bloody stools/day, abdominal pain, fever, and tachycardia. Bloods: Hb 9 g/dL, CRP 110, albumin 28. AXR shows no perforation. Management: Admitted under gastroenterology. IV hydrocortisone, IV fluids, LMWH prophylaxis, and daily monitoring. Rescue infliximab discussed if no response at 72h. Outcome: Improved on IV steroids. Discharged on tapering oral prednisolone + azathioprine for maintenance.
Case 3 (Complicated UC – toxic megacolon): 🚨 A 45-year-old man with long-standing pancolitis presents with abdominal distension, fever, and shock. AXR shows dilated transverse colon >6 cm with loss of haustra. Management: Emergency resuscitation, broad-spectrum antibiotics, IV steroids, and urgent surgical referral. Subtotal colectomy performed due to perforation risk. Outcome: Recovered post-operatively with ileostomy. Planned for later pouch surgery. Histology confirmed extensive UC with transmural inflammation.

🧑‍⚕️ Teaching Commentary

Ulcerative colitis is a chronic inflammatory bowel disease with continuous mucosal inflammation starting at the rectum. • Case 1 shows typical mild–moderate disease, often well controlled with 5-ASA. • Case 2 illustrates severe acute colitis — a medical emergency needing IV steroids and close monitoring. • Case 3 highlights toxic megacolon 🚩, a life-threatening complication requiring urgent surgery. Long-term complications include colorectal cancer, so patients need regular colonoscopic surveillance after 8–10 years of disease duration.

PLEASE NOTE LEGAL ADVICE: The contents are under continuing development and improvements and may contain errors of omission or fact. Feedback vital and always welcome at drokane at gmail.com. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice. It is only for educational purposes. Please adhere to your local protocols. If you are unwell please seek healthcare advice from your doctor. This does not replace senior or specialist advice. If you do not accept this then please do not use the website. If you need medical advice, please consult a doctor or other appropriate medical professional. If you are a medical professional and you need advice then speak to your senior or colleagues.

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