Ulcerative Colitis

Pathology

• Predominantly mucosal disease, possible auto-immune producing crypt abscesses

• Usual age at onset is 20-40; another peak at 60-70; equal male:female ratio

Clinical

• Recurrent episodes of bloody diarrhea

• Electrolyte depletion

• Abdominal pain

• Fever

• Periods of exacerbation and remission

• Iritis, erythema nodosum, pyoderma gangrenosum

• Pericholangitis, chronic active hepatitis, sclerosing cholangitis, fatty liver

• Spondylitis, peripheral arthritis, RA (10-20%)

• Thrombotic complications

Location

• Begins in rectum with retrograde progression

• Rectosigmoid involved 95%; continuous involvement of L colon

• Terminal ileum in 5-10% with backwash ileitis

X-Ray Manifestations

• Acute inflammatory stage

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 UC)

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

• Widening of the presacral space

• Subacute stage

• Coarser, more granular mucosa

• Inflammatory polyps= frondlike lesions of inflamed mucosa

• Chronic stage

• Shortening of the colon=may be from spasm of longitudinal muscles or from irreversible fibrosis (lead-pipe colon)

• Loss of haustrations on left side of colon

• Postinflammatory polyps=filiform polyps=long worm-like lesions

• Backwash ileitis (5-10%)=wide open ileocecal valve and dilated terminal ileum

Differential Diagnosis

• Crohn’s disease–skip lesions: R colon; TI abnormal

• Cathartic colon-loss of haustrations on Right side of colon; rectum spared

• Familial polyposis–multiple polyps but no inflammatory changes

• Radiation ileitis–should have other loops involved and appropriate hx

• Lymphoma–should have tumor masses, less spasm

• Amebiasis–cone-shaped cecum

Extra-intestinal Manifestations

• Fatty infiltration of the liver

• Gallstones (28-34%)

• Sclerosing cholangitis

• Bile duct carcinoma

• Amyloidosis

• Urolithiasis:oxalate/uric acid stones

• Migratory arthritis

• Sacroiliitis and ankylosing spondylitis

• Erythema nodosum and uveitis

Complications

• Toxic megacolon

• Adenocarcinoma of the colon (1-16%)

• Increased risk of developing ca of colon with long-standing (usually more than 25 years) ulcerative colitis

• Higher incidence of multiple carcinomas

• Usually involve distal transverse colon, descending colon and rectum

• May present with smooth, tapering edges and resemble a benign stricture or may be annular constricting lesions

• Colonic strictures (10%)

• Smoothly tapering edges, usually single, commonly in sigmoid; must be differentiated from ca