Unlike Crohn disease, inflammation in ulcerative colitis is limited to the mucosal layer of the colon. The rectum is virtually always involved, with inflammation extending proximally in a confluent fashion. The extent of proximal involvement is variable. A significant proportion of patients have disease confined to the rectum (ulcerative proctitis). Roughly one third of patients have proctosigmoiditis, and the majority of patients have gross colitis only distal to the splenic flexure.Approximately one third of patients have disease that extends proximal to the splenic flexure (extensive colitis), often involving the entire colon (pancolitis or universal colitis). On occasion a so-called cecal patch of periappendiceal inflammation is encountered. This does not represent a true skip lesion suggestive of Crohn disease. Similarly, limited ileal involvement (backwash ileitis) can be seen in patients with ulcerative colitis who have pancolonic disease. Deep ileal ulcers,long segments of ileal involvement,or stricturing disease are consistent with Crohn disease and not ulcerative colitis. Although confluent disease involving the rectum is the rule in ulcerative colitis,patients on medical therapy,particularly topical therapy, may have apparent skip lesions or rectal sparing. This should be recognized as a treatment effect and not a manifestation of Crohn disease. Unlike Crohn disease,ulcerative colitis is frequently acute or subacute in onset. Like Crohn disease, the subsequent clinical course is one of recurring episodes of symptomatic disease interspersed with episodes of relative (or complete) quiescence.
Ulcerative Colitis Symptoms and signs
As with Crohn disease, the symptoms of ulcerative colitis depend on the extent and severity of inflammation.Overt rectal bleeding and tenesmus are virtually universally present and may be the only symptoms in patients with proctitis alone. When the proximal colon is involved,diarrhea and abdominal pain are more frequent complaints. Nausea and weight loss portend more severe disease. Severe abdominal pain or fever suggests fulminant colitis or toxic megacolon.
Signs of ulcerative colitis include mild abdominal tenderness, often most localized in the hypogastrium or left lower quadrant.Digital rectal examination may disclose visible red blood. As with Crohn disease, signs of malnutrition may be evident. Severe tenderness, fever, or tachycardia heralds fulminant disease
Ulcerative Colitis Diagnostic
No single symptom, physical finding, or test result can diagnose IBD.The diagnosis of both Crohn disease and ulcerative colitis is a clinical one, based on compatible patient history; physical examination; and laboratory, radiographic, endoscopic, and histological findings. Diagnostic tools have been discussed at length in the preceding sections. A detailed discussion of the histologic findings of IBD is beyond the scope of this chapter.Noncaseating granulomas and transmural disease both are highly specific to Crohn disease.Colonic biopsies in both ulcerative colitis and Crohn colitis demonstrate evidence of acute inflammation, characterized by neutrophilic cryptitis, and chronic inflammation, such as crypt distortion and a plasmacytic infiltration of the lamina propria.A skilled pathologist is indispensable in helping to characterize the histologic findings and make the diagnosis of IBD.
For both the initial diagnosis and subsequent flares,other conditions that mimic IBD should be excluded (see next section).Of particular importance is the exclusion of infectious pathogens,as the treatment of active IBD frequently involves immunosuppressive medications. For patients who do not respond to medical therapy (or worsen despite it), the diagnosis of IBD should be rechallenged.
Ulcerative Colitis Treatment
The primary goal of medical therapy for IBD is directed toward the relief of clinical symptoms. For both Crohn disease and ulcerative colitis, medical therapy is generally considered as a two-step approach:(1) achieving remission from symptoms of active disease, and (2) maintaining remission. To a large extent, the clinical presentation dictates the choice of pharmaceutical agent. Patients with severe disease generally require more aggressive therapy, whereas patients with milder disease may do well with less potent medications, or no therapy at all. All medical therapeutic options carry risks of toxicity, and this risk must be considered carefully against the potential benefit.
The secondary goal of preventing IBD-related complications has only recently become a serious consideration.Recent studies have suggested that medical therapy may help prevent postoperative recurrence of Crohn disease, or reduce the risk of CRC in ulcerative colitis.Preventing complications may also mean avoiding medical therapies. The goal of achieving steroid-free remission is now well-recognized in IBD care.
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