17 Ulcerative colitis

Questions

What are the main pathological features of ulcerative colitis?

What features would you see on a barium enema?

What is the main long-term complication and how can you prevent it?

Ulcerative colitis is a chronic relapsing and remitting inflammatory bowel disease that causes inflammation of the mucosa and submucosa of the large bowel only. It affects both sexes equally and is most common in those aged 20–40 years. The cause of ulcerative colitis is not known, although the following associations exist: genetic (family members have a 10–15% increased risk; association with HLA-B27), environmental/dietary (low-fibre diet, additives, viral or bacterial pathogens), stress (can cause relapses). Smoking is protective.

Pathology

Ulcerative colitis starts in the rectum and extends continuosly proximally, without leaving normal patches of mucosa. Pancolitis affects the whole colon, proctitis only the rectum. Rarely it affects the terminal ileum when ‘back wash’ occurs at the ileocaecal valve (backwash ileitis). Infiltration of lymphocytes and neutrophils into the colonic glands (crypts of Lieberkühn) gives rise to crypt abscesses. Psuedopolyps are intact islands of normal muscosa. See Fig. 3.18.1 for a comparison with Crohn’s disease.

Fig. 3.17.1 Plain radiograph showing toxic megacolon (notice the uneven mucosal surfaces).

Clinical features

Presentation is commonly with a triad of gradual-onset diarrhoea (with blood and mucus), abdominal pain and weight loss.

Early or limited disease

Anaemia, anorexia and crampy lower abdominal pain (relieved by defecation) may be present.

Acute disease

There may be signs of peritonitis, septicaemia, severe bleeding and weight loss; this may be toxic dilatation (below).

Extracolonic manifestation of inflammatory bowel disease (HLA-B27 associations): eyes (iritis, conjunctivitis), joints (arthralgia, ankylosing spondylitis, sacroiliitis), skin (pyoderma gangrenosum, erythema nodosum) and liver (chronic active hepatitis, primary sclerosing cholangitis).

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