Ulcerative Colitis, Physiopathology, Diagnosis, Treatment

Definition
It represents an intestinal inflammatory disease, characterized by recurrent attacks of diarrhea with mucus and blood, alternating with periods of silence.

Clinical features of ulcerative colitis
Digestive manifestations consist in episodes of diarrhea with blood, mucus and pus. The diarrheic episodes consist usually 3-10 stools/day, and in the severe cases there may only appear emissions of blood, mucus and pus. Abdomen on being palpated is painful in the hypogastric area or along the course of the colon.

Extradigestive manifestation are: anemia, fever or low-grade fever in the episode, weight loss, and fatigue. Sometimes arthritis, erythema nodosum, uveitis may appear.

Physiopathology
In the physiopathology of inflammatory bowel disease, more factors are incriminated:
a) Environment factors: the normal intestinal microflora
b) Immunologic factors: defects of local immunity of the mucosa.
c) Genetic factors.

Paraclinical findings
Laboratory data: iron-deficiency anemia,with hypochromia and low sideremia, hypoalbuminemia, inflammatory syndrome (ESR increased,sometimes leukocytosis, reactive C protein increased).
Stool examination is useful in order to exclude an infectious disease such as bacterial dysentery.
Endoscopic data.Typically for ulcerative colitis is the permanent involvement of rectum (recto-colitis), the continuous character of endoscopical lesions. The endoscopy shows the typical aspect of the episode: the mucosa “cries blood”. The mucosa is frail, with superficial ulcerations, diffuse erythema, loss of typical vascular pattern, covered with mucus and pus. The pseudopolyps may be present.
The biopsy proving an inflammatory infiltrate with polimorphonuclear cells at the level of mucosa,  the presence of cryptic abcesses, exulcerations.

Radiological examination. The barium enemawill show, in chronic stages, a granular aspect of the affected mucosa, the pseudopolyps, and the loss of normal colonic haustrations, with a tubular aspect of the colon.

Transabdominal ultrasonography  showing the thickness of colonic wall in the acute phase of the colonic extension. The colonic mucosa is thickened more than 5 mm (mostly 7-10 mm).

Positive diagnosis: diarrhea with blood, mucus and pus, the endoscopically, followed by the biopic confirmation.

Clinical forms

• Fulminant
• Chronic intermittent
• Chronic continuous

The assessment of severity is made by number of stools and intensity of clinical signs. Therefore, there are moderate, mild and severe forms:

• the mild form presents up to 4 stools/day, with only little blood and mucus, general state is good, without fever or denutrition, the anemia is discrete;
• the moderate form with 4-6 stools/day, anemia, low-grade fever
• the severe form with more than 6 stools/day, fever over 38 grade Celsius, anemia, hypoalbuminemia, big amount of blood in the stools, general feeling of illness.

 Based on the location of ulcerative colitis there are three forms:

• proctitis or proctosigmoiditis (rectal or rectosigmoidian location)
• left colitis (involvement up to the splenic angle)
• pancolitis (involvement of the whole colon).

Differential diagnosis:

• colon neoplasia - the endoscopic examination will certify the diagnosis
• bacterial dysentery or other infections causes: Salmonella, Shigella, Campilobacter jejuni, Clostridium difficile - the stool examination will prove the germ
• ischemic colitis - endoscopic and bioptic diagnosis
• irradiation colitis - history of therapeutic abdominal diagnosis
• collagen colitis or lymphocytar colitis-with a normal endoscopic; the biopsy will reveal the presence of submucosal collagenous bands or a rich lymphocytary infiltrate.
• Chron’s  disease -characterized by discontinuity of lesions, endoscopically deep ulcerations, sometimes linear.

Evolution
The evolution is cyclic- acute episodes of variable duration, usually weeks or months, followed by remission.

Complications

• the toxic megacolon
• intestinal stenosis
• massive bleeding with severe anemia
• colon cancer
• extradigetive severe manifestations. 

Treatment ulcerative colitis
a. Hygienic and dietary

The diet during the episode will be sparing the digestive function, by avoiding milk and dairy meals  (cream, fermented chesse), raw vegetables and fruit, concentrated sweets.

b.Medication - it depends on the episode severity.
In the severe episode, parenteral nutrition must be used, with liquidian and electrolytes correction, corticotherapy pev. -100-200 mg hydrocortisone hemisuccinate/day and in toxico-septic forms, antibiotherapy, especially against anaerobic germs (Metronidazole). In refractory fulminant Ulcerative colitis, cyclosporine has effectively induced remission, obviating immediate surgery. Because cyclosporine is such a potent immunosuppressive agent, the psysician must be absolutely certain that an infection is not contributing to the colitis. Infliximab is a monoclonal antibody against tumor necrosis factor (TNF)-alpha, a proinflammatory cytokine that occurs early in the inflammatory cascade. Infliximab has only recently been approved for use in ulcerative colitis. The drug is given as an intravenous infusion, typically in an induction regimen of 2 infusions over 2 weeks. In several reports, refractory ulcerative colitis responded to infliximab, and emergency colectomy was avoided.
In moderate forms of ulcerative colitis (4-6 stools/day) the treatment is using prednisone 60mg/day; the doses sre tapered with approx. 10 mg/week, so that after approx. 4-6 weeks the necessary dose to suppress the disease activity is 10 mg/day; the treatment is continued, even if remission is evident, for more than 6 months. The alternative is treatment with Salazopirine 4-6g/day or, more modern, 5-aminosalicylic acid (Mesalazine) 3-4g/day.
In distal forms (rectosigmoidian) a local treatment with suppositories, foam or Salazopirine or 5-aminosalicyclic enemas may be  used, or topic corticoids (Budesonide).
In mild forms, a treatment with mesalazine 2-3g/day or Salazopirine 3-4g/day is administered.
In continuous chronic forms, the treatment is indefinite.
In discontinuous chronic forms, the acute episode is treated with higher doses, and with endoscopic and histological remission, it keeps up with Salazopirine 4-6 g/day or Salofalk 3-4 g/day.

c. Surgical treatment in case of toxic megacolon, when there is a perforation or an uncontrolled bleeding a total colectomy or proctocolectomy has to be done