General information
• It is an inflammatory disease characterized by involvement of only the colon (rarely terminal ileum) in the GI lumen and progresses with remissions and exacerbations.
• It is less common in smokers.
• The most common site of involvement is the rectum, the inflammation almost always starts from the rectum and progresses towards the cecum.
Prevalence of Disease in Ulcerative Colitis
Proctitis .......... Rectum only
Distal colitis .... Recto-sigmoid or up to 60 cm (40-50% of cases rectum or rectosigmoid)
Left colitis ........ Limited to splenic flexure
Diffuse colitis.... Extending to the transverse colon
Pancolitis.. ...... Entire colon including cecum (10-20% of all cases)
Pathology
Inflammation is superficial, rarely passes the lamina propria, does not involve the serosa.
Intestinal involvement is diffuse, there is no solid region in between.
In cases involving the cecum, 2-3 cm of terminal ileum may be involved (Backwash ileitis).
Apart from this, pathology is seen only in the colon in the GIS.
Crypt abscesses (PNL cells accumulating in the crypt lumen during the acute phase of inflammation) are observed in pathologically involved areas.
Postinflammatory pseudopolyps may develop.
In the chronic period, a lead pipe view may occur (loss of aspiration, thickening of smooth muscle, shortening of the colon).
Clinic
• Although it varies according to the extent of the disease, rectal bleeding, tenesm and mucopurulent stool are common. The most common complaint that brings the patient to the clinic is bloody diarrhea.
• There may be systemic symptoms such as fever, fatigue, night sweats, arthralgia.
• Abdominal pain is not expected except in severe cases.
• Tympanism, distention, fever, tachycardia, vomiting should suggest fulminant colitis and toxic megacolon.
• Iron deficiency anemia is common in the laboratory. Acute phase reactants may be elevated, but they are not helpful in diagnosis and treatment.
• As autoantibodies, p-ANCA is detected in 50-80% of cases.
• Extraintestinal findings:
In general, the most common mucocutaneous findings are seen. Oral aphthous ulcers are the most common mucosal lesions.
Skin: Erythema nodosum, pyoderma gangrenosum, necrotizing vasculitis
Joint: Peripheral arthritis, ankylosing spondylitis, sacroileitis
Eye: Conjunctivitis, anterior uveitis/iritis, episcleritis, keratitis
Liver: Adiposity, sclerosing cholangitis, pericholangitis
Hematologic: Leukocytosis, thrombocytosis, iron deficiency anemia
Other: Stomatitis, amyloid development, kidney uric acid stones, venous thrombosis
• Extraintestinal findings are generally associated with disease activity.
Extraintestinal findings independent of disease activity
• Primary sclerosing cholangitis (may develop even after colectomy)
• Uveitis (may develop even after colectomy)
• Sacroileitis
• Ankylosing spondylitis
• Pyoderma gangrenosum
• Primary sclerosing cholangitis (PSK)
It is expected in approximately 5% of all patients in the course of ulcerative colitis.
On the other hand, 60% of PSK patients have ulcerative colitis.
Since there is no relationship between PSC and the activity of ulcerative colitis, every patient diagnosed with PSC is investigated for the possibility of underlying ulcerative colitis.
Complications
• Toxic megacolon
It is the most important and mortal complication.
The colon wall becomes thinner like a parchment paper and the risk of spontaneous perforation increases.
Toxic megacolon is most commonly seen in the transverse colon, and direct abdominal X-ray is taken for diagnosis.
Localized enlargement of more than 6 cm on the direct radiograph makes the diagnosis of toxic megacolon.
Barium radiography and colonoscopy are contraindicated because of the risk of perforation.
• Colon cancer
The risk of colon cancer increases as the duration and extent of the disease increase.
This increase is 8-10 of the disease. starts after the year.
The risk is highest in pancolitis. 8-10 in these patients. Colonoscopic follow-up and biopsy are performed every 1-3 years after 1 year. Cancer risk is lower in cases confined to the left colon only. Colonoscopic follow-up is recommended after 15 years.
Pseudopolyps do not play a role in cancer formation, cancer starts directly from the damaged mucosa.
• Other Complications such as massive hemorrhage, perforation, thromboembolism, stricture and obstruction may rarely be seen. Perianal disease is rare.
Diagnosis
For diagnosis, other causes of colitis should be excluded and clinical, laboratory, endoscopic and pathological findings of the disease should be evaluated together.
Acute phase reactants, especially CRP, are high. It also gives an idea about the activity of the disease. Increase in sedimentation rate, leukocytes and platelets; A decrease in hemoglobin and albumin can be observed.
• Fecal lactoferrin and especially calprotectin in stool reflect intestinal inflammation and help in differential diagnosis, determination of activity and follow-up.
• Endoscopy: A mucosa that bleeds easily, edematous, fragile, hyperemic and granular is typical. Superficial and irregular ulcers are seen. Pseudopolyps are seen in the chronic phase.
• Radiology: Mucosal irregularity due to ulceration and pseudopolyps, shortening of the colon and loss of haustration in the late period are seen in double contrast colon radiography.
• Pathology: Mucosal inflammation and crypt abscesses support the diagnosis.
Treatment
First of all, it is aimed to put the patient into remission and then to maintain remission to prevent relapses. Medical treatment is not curative.
• 5-Amino Salicylic Acid (5-ASA): Topical {rectal) or oral sulfasalazine or mesalamine (sulfasalazine consists of sulfapyridine and 5-ASA, mesalamine only 5-ASA).
It is the main drug of treatment in mild to moderate cases and is used in almost every case.
Rectal topical application may be sufficient only in cases with distal colon and rectum involvement.
It is effective in both achieving and maintaining remission in mild to moderate cases.
• Corticosteroids
It is used in cases unresponsive to 5-ASA therapy and in moderate-to-severe colitis.
Topical (budesonide) can be given rectally in cases with distal colitis.
They are used parenterally with fulminant colitis.
Once symptoms are under control, steroids are tapered off. Systemic steroids are not used in maintenance therapy.
• Immunosuppression
6-mercaptopurine or azathioprine is used in maintenance therapy to reduce steroid dependence in frequently relapsing, severe and widespread colitis.
Its effects begin in an average of 2 months. Not used to put into remission. It is used for maintenance of remission.
Cyclosporine can be used with severe steroid-refractory colitis and fulminant colitis.
Cyclosporine is effective in both remission and maintenance.
• TNF-alpha antagonists (infliximab, adalimumab, golimumab, certolizumab)
They are used in severe steroid-resistant or dependent colitis.
It is effective in both remission and maintenance.
• Monoclonal antibodies
Monoclonal antibodies developed against alpha-4 integrins are used in anti-TNF resistant cases. Drugs in this group are vedolizumab and natalizumab.
Natalizumab can cause progressive multifocal leukoencephalopathy.
Ustekinumab {anti IL12/23) can be used in resistant cases.
• Fulminant colitis treatment
Oral feeding is stopped, total parenteral feeding is given.
IV steroids are started, IV cyclosporine and infliximab may also be tried.
If there is a risk of toxic megacolon, broad-spectrum antibiotics are added.
Toxic megacolon and fulminant colitis cases that do not respond to medical treatment are treated surgically.
• Surgery: In case of toxic megacolon, perforation, unceasing bleeding, severe dysplasia in biopsy and unresponsiveness despite medical treatment, proctocolectomy can be performed and cured.
Medications for ulcerative colitis according to their use in acute or maintenance therapy
5-ASA Steroids Azathioprine Cyclosporine Anti-TNF
acute + + - + +
Maintain + - + + +