Pathology
o
Predominantly
mucosal disease,
possible
auto-immune
producing crypt
abscesses
o
Usual age at onset
is 20-40; another
peak at 60-70
o
Equal male:female
ratio
Clinical
o
Recurrent episodes
of bloody diarrhea
o
Electrolyte
depletion
o
Abdominal pain
o
Fever
o
Periods of
exacerbation and
remission
o
Iritis, erythema
nodosum, pyoderma
gangrenosum
o
Pericholangitis,
chronic active
hepatitis,
sclerosing
cholangitis, fatty
liver
o
Spondylitis,
peripheral
arthritis, RA
(10-20%)
o
Thrombotic
complications
Location
o
Begins in rectum
with retrograde
progression
o
Rectosigmoid
involved 95%;
continuous
involvement of
left colon
o
Terminal ileum in
5-10% with
backwash ileitis
X-Ray
Manifestations
·
Acute inflammatory
stage
o
Spasm and
irritability
o
Fine mucosal
granularity=earliest
finding on
air-contrast BE
o
Spiculated,
serrated bowel
margins from tiny,
multiple
ulcerations
o
Collar button
ulcers-from
undermining (not
specific for
ulcerative colitis)
o
Double-tracking=long,
longitudinal
ulcers in
submucosa
o
Thumbprinting=from
edema of wall
o
Pseudopolyps=scattered
islands of
edematous mucosa
in a sea of
ulcerated mucosa
o
Widening of the
pre-sacral space
·
Subacute stage
o
Coarser, more
granular mucosa
o
Inflammatory
polyps=
frond-like
lesions of
inflamed mucosa
·
Chronic stage
o
Shortening of the
colon-may be from
spasm of
longitudinal
muscles or from
irreversible
fibrosis
(lead-pipe colon)
o
Loss of
haustrations on
left side of colon
Barium enema
examination
demonstrates loss of
haustral folds in the
entire descending
colon with small
ulcerations suggested.
The colon has a
"lead-pipe"
appearance.
The distribution and
appearance are
suggestive of
ulcerative colitis.
Click here for a
larger version of the
same photo
o
Post-inflammatory
polyps=filiform
polyps=long
worm-like lesions
o
Backwash ileitis
(5-10%)=wide open
ileocecal valve
and dilated
terminal ileum
Differential
Diagnosis
o
Crohn’s disease–skip
lesions: R colon;
TI abnormal
o
Cathartic colon-loss
of haustrations on
Right side of
colon; rectum
spared
o
Familial polyposis–multiple
polyps but no
inflammatory
changes
o
Radiation ileitis–should
have other loops
involved and
appropriate hx
o
Lymphoma–should
have tumor masses,
less spasm
o
Amebiasis–cone-shaped
cecum
Extra-intestinal
Manifestations
o
Fatty infiltration
of the liver
o
Gallstones
(28-34%)
o
Sclerosing
cholangitis
o
Bile duct
carcinoma
o
Amyloidosis
o
Urolithiasis: oxalate/uric acid stones
o
Migratory
arthritis
o
Sacroiliitis and
ankylosing
spondylitis
o
Erythema nodosum
and uveitis
Complications
o
Toxic megacolon
o
Adenocarcinoma of
the colon (1-16%)
·
Increased risk of
developing ca of
colon with
long-standing
(usually more than
25 years)
ulcerative colitis
o
Higher incidence
of multiple
carcinomas
o
Usually involve
distal transverse
colon, descending
colon and rectum
o
May present with
smooth, tapering
edges and resemble
a benign stricture
or may be annular
constricting
lesions
o
Colonic strictures
(10%)
o
Smoothly tapering
edges, usually
single, commonly
in sigmoid; must
be differentiated
from ca
