Colitis, Ulcerative

Key Features

Essentials of Diagnosis

• Bloody diarrhea

• Lower abdominal cramps and fecal urgency

• Anemia, low serum albumin

• Negative stool studies for pathogens

• Sigmoidoscopy is key to diagnosis

General Considerations

• Idiopathic inflammatory condition that involves the mucosal surface of the colon, resulting in diffuse friability and erosions with bleeding

• One-fourth of patients have disease confined to the rectosigmoid region (proctosigmoiditis); one-half have disease that extends to the splenic flexure (left-sided colitis); and one-fourth have disease that extends more proximally (extensive colitis)

• In patients with distal colitis, the disease progresses with time to more extensive involvement in 25%

• Most affected patients experience periods of symptomatic flare-ups, periods of mild activity, or remission

• Approximately 15% may have an aggressive course with increased risk for hospitalization or surgery

• Of patients hospitalized with severe colitis, colectomy is required in up to 30% for unresponsive or 'fulminant' disease

Demographics

• More common in nonsmokers and former smokers, severity may worsen in patients who stop smoking

• Appendectomy before age 20 reduces risk

Clinical Findings

Symptoms and Signs

• Bloody diarrhea

• Cramps, abdominal pain

• Fecal urgency, tenesmus, extraintestinal symptoms

• Tenderness, evidence of peritoneal inflammation

• Bright red blood on digital rectal examination

Mild disease

• Fewer than 4–6 bowel movements per day

• Rectal bleeding

• Stools may be formed or loose

• Left lower quadrant cramps, relieved by defecation

• No significant abdominal pain or tenderness

• Mild anemia and hypoalbuminemia

Moderate disease

• Diarrhea more severe with frequent bleeding

• Abdominal pain and tenderness (but not severe)

• Mild fever, anemia, and hypoalbuminemia

Severe disease

• > 6 bloody bowel movements per day

• Signs of hypovolemia and impaired nutrition

• Abdominal pain and tenderness

Fulminant disease

• Rapid progression of symptoms and signs of severe toxicity (hypovolemia, hemorrhage requiring transfusion, and abdominal distention with tenderness) over 1–2 weeks

Toxic megacolon

• Colonic dilation of > 6 cm on radiographs with signs of toxicity, occurring in < 2% of ulcerative colitis patients, heightens risk of perforation

Extracolonic manifestations

• Occur in 50% of cases

• Oral ulcers

• Erythema nodosum, pyoderma gangrenosum

• Episcleritis or uveitis

• Spondylitis or sacroiliitis

• Thromboembolic events

• Oligoarticular or polyarticular nondeforming arthritis

• Sclerosing cholangitis

Differential Diagnosis

• Infectious colitis

  • Salmonella

  • Shigella

  • Campylobacter

  • Amebiasis

  • Clostridioides difficile

  • Enteroinvasive Escherichia coli

• Ischemic colitis

• Crohn disease

• Diverticular disease

• Colon cancer

• Antibiotic-associated diarrhea or pseudomembranous colitis

• Infectious proctitis: gonorrhea, chlamydia, herpes, syphilis

• Radiation colitis or proctitis

• Cytomegalovirus colitis in immunocompromised persons

Diagnosis