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TainaSipponen

Ulcerative Colitis

Essentials

  • Ulcerative colitis may be the cause of recurrent or prolonged (bloody) diarrhoea.
  • Treatment decisions and medication choices are based on the severity of the symptoms and the extent of the disease (proctitis, left-sided colitis or extensive colitis).
  • Patients with acute severe colitis require hospitalisation.
  • Owing to the increased risk of developing carcinoma, regular endoscopic screening is indicated in ulcerative colitis.

Epidemiology

  • The occurrence of ulcerative colitis is high in the Nordic countries, Western Europe, North America and Australia. The annual incidence in Finland is about 25 new cases/100 000 individuals/year, and the prevalence rate is about 550/100 000 individuals.
  • The pathogenetic mechanism is not known.
  • Having close relatives with an inflammatory bowel disease increases the risk of developing ulcerative colitis.

Signs and symptoms

  • Diarrhoea, stools mixed with blood and mucus, abdominal pain, sometimes weight loss. The symptoms have usually persisted for several weeks or months.
  • Recurrent relapses are typical as are remissions, either spontaneous or drug-induced. About 10-20% of patients have continuous symptoms.
  • The disease can be divided into mild, moderate and severe forms (table T1).

The severity of ulcerative colitis

SeverityDefinition
Mild colitisDiarrhoea < 4 times / 24 hours (with or without blood), no systemic symptoms, Hb > 115 g/l, normal inflammatory markers
Moderate colitisDiarrhoea > 4 times / 24 hours, absent or mild systemic symptoms, Hb ≥ 105 g/l, normal inflammatory markers
Severe colitisDiarrhoea ≥ 6 times / 24 hours and tachycardia, fever, Hb < 105 g/l, elevated inflammatory markers (ESR > 30 mm/h and/or CRP > 30 mg/l)
  • Extraintestinal involvement is possible (arthritis, uveitis, episcleritis, erythema nodosum, pyoderma gangrenosum and primary sclerosing cholangitis).

Diagnosis and investigations

  • Complete blood count, CRP, plasma creatinine and albumin, ALT, ALP, tissue transglutaminase antibodies, faecal calprotectin, stool culture or faecal nucleic acid testing for bacteria, feacal nucleic acid testing for Clostridium difficile toxin gene.
  • Ileocolonoscopy: loss of the typical vascular pattern, mucosal erythema, easy bleeding upon touch, erosions and ulcerations
    • Classification of the extent of inflammatory changes:
      • limited to the rectum, i.e. proctitis
      • left-sided colitis or
      • extensive colitis (the changes extend past the splenic curve)
    • Classification of the severity of inflammatory changes:
      • mild: decreased vascular pattern, mild erythema, mild contact bleeding
      • moderate: erythema, absent vascular pattern, contact bleeding, erosions
      • severe: erythema, absent vascular pattern, contact bleeding, spontaneous bleeding, ulceration, mucopurulent exudate
  • The histological findings are typical but not specific (diffuse acute and chronic inflammatory changes that are limited to the mucosa and submucosa; ulceration as the inflammation worsens).
    • Biopsies are necessary even when the colonic mucosa has a normal appearance.
  • The clinical criteria for severe colitis
    • Diarrhoea > 6 times / 24 hours and one of the following:
      • fever > 37.5 °C
      • tachycardia > 90/min
      • anaemia, Hb < 105 g/l
      • ESR > 30 mm/h or CRP > 30 mg/l.

Differential diagnosis

Treatment Omega 3 Fatty Acids for Maintenance of Remission in Ulcerative Colitis, Lymphoma Risk Among Inflammatory Bowel Disease Patients Treated with Azathioprine or 6-Mercaptopurine, Fish Oil for Induction of Remission in Ulcerative Colitis, Probiotics for Induction of Remission in Ulcerative Colitis, Methotrexate for Induction of Remission in Ulcerative Colitis, Tacrolimus (Fk506) for Induction of Remission in Refractory Ulcerative Colitis, Vedolizumab for Induction and Maintenance of Remission in Ulcerative Colitis, Open Versus Laparoscopic (Assisted) Ileo Pouch Anal Anastomosis for Ulcerative Colitis and Familial Adenomatous Polyposis, Methotrexate for Maintenance of Remission in Ulcerative Colitis, Probiotics Versus Mesalazine or Placebo for Maintenance of Remission in Ulcerative Colitis, Oral 5-Aminosalicylic Acid for Maintenance of Remission in Ulcerative Colitis, Curcumin for Maintenance of Remission in Ulcerative Colitis

Arrangement of treatment

  • Indications for a referral to a specialist
    • The symptoms of a recurrent episode are not alleviated within 1-2 weeks.
    • Glucocorticoids cannot be withdrawn after 3 months of therapy.
    • Pregnancy, even if no symptoms are present
    • Extraintestinal manifestations (liver, skin, joints, lower back, eyes)

Follow-up

  • Endoscopic monitoring Colonoscopic Surveillance for Cancer in Ulcerative Colitis, Strategies for Detecting Colon Cancer and/or Dysplasia in Patients with Inflammatory Bowel Disease
    • The activity and extent of symptomatic disease is monitored with colonoscopy as necessary.
    • Owing to the risk of cancer, colonoscopy is recommended for all patients with ulcerative colitis about 8 years after symptom onset. Thereafter, follow-up examinations are programmed to take place every 1-5 years as dictated by e.g. disease duration, associated diseases and the extent and activity of the disease in order to detect the development of dysplasia. Severe dysplasia, or repeatedly detected mild dysplasia, is an indication for surgery.
      • In colitis limited to the rectum, i.e. proctitis, endoscopy follow-up is not required.
  • Laboratory monitoring
    • Monitoring clinical activity: basic blood count with platelets, CRP and faecal calprotectin
    • Monitoring drug therapy: basic blood count with platelets (including neutrophils during azathioprine or mercaptopurine therapy), ALT, alkaline phosphatase, creatinine (during 5-ASA therapy)

    References

    • Jussila A, Virta LJ, Kautiainen H et al. Increasing incidence of inflammatory bowel diseases between 2000 and 2007: A nationwide register study in Finland. Inflamm Bowel Dis 2011. [PubMed]
    • Magro F, Gionchetti P, Eliakim R ym. Third European Evidence-based Consensus on Diagnosis and Management of Ulcerative Colitis. Part 1: Definitions, Diagnosis, Extra-intestinal Manifestations, Pregnancy, Cancer Surveillance, Surgery, and Ileo-anal Pouch Disorders. J Crohns Colitis 2017;11(6):649-670. [PubMed].
    • Harbord M, Eliakim R, Bettenworth D ym. Third European Evidence-based Consensus on Diagnosis and Management of Ulcerative Colitis. Part 2: Current Management. J Crohns Colitis 2017;11(7):769-784. [PubMed]
    • Maaser C, Sturm A, Vavricka SR, et al. ECCO-ESGAR Guideline for Diagnostic Assessment in IBD Part 1: Initial diagnosis, monitoring of known IBD, detection of complications. J Crohns Colitis 2019;13(2):144-164. [PubMed]
    • Øresland T, Bemelman WA, Sampietro GM et al. European evidence based consensus on surgery for ulcerative colitis. J Crohns Colitis 2015;9(1):4-25. [PubMed]
    • Sands BE, Sandborn WJ, Panaccione R, et al. Ustekinumab as Induction and Maintenance Therapy for Ulcerative Colitis. N Engl J Med 2019;381(13):1201-1214. [PubMed]
    • Sandborn WJ, Su C, Sands BE, et al. Tofacitinib as Induction and Maintenance Therapy for Ulcerative Colitis. N Engl J Med 2017;376(18):1723-1736. [PubMed]