Ulcerative Colitis

Welcome to today’s episode where we’re diving into Ulcerative Colitis, exploring its symptoms, diagnosis, risk factors, and treatment options.

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Transcript

Welcome to today’s episode where we’re diving into Ulcerative colitis. This is a chronic condition that primarily involves the rectum and can extend proximally to affect part or all of the colon. It's a complex disease with varying degrees of severity. 

Let's start with the basics—what exactly happens in ulcerative colitis?

In ulcerative colitis, there’s diffuse mucosal inflammation, which leads to friability, erosions, and ulcers in the colon, causing bleeding. Patients will go through periods of flare-ups, followed by periods of mild activity or remission. What’s interesting is that non-smokers and former smokers are more likely to get it, while active smokers may actually have lower disease severity. But if they quit smoking, the disease can worsen.

That’s really interesting, so smoking seems to have some sort of protective effect, at least for ulcerative colitis. So, when a patient comes in, what symptoms do we look for?

The hallmark symptom is bloody diarrhea. You need to ask patients about things like stool frequency, how much rectal bleeding they have, any abdominal cramps, fecal urgency, tenesmus-that feeling of incomplete evacuation, and if they have any extraintestinal symptoms.

So when we do the physical exam, what should we be looking for?

On abdominal examination, tenderness is common, and you might see signs of peritoneal inflammation. If you perform a digital rectal exam, you could see red blood as well.

Interesting! So, how do we differentiate between mild, moderate, and severe cases?

Great question! For mild to moderate disease, you typically see fewer than four to six bowel movements per day, mild to moderate rectal bleeding, and no constitutional symptoms like fever. They might also have fecal urgency, tenesmus, and left lower quadrant cramps that are relieved by defecation. There might also be mild anemia and hypoalbuminemia. But for severe disease, it’s more serious: more than six bloody bowel movements per day, leading to severe anemia, hypovolemia, and impaired nutrition. There’s usually abdominal pain and tenderness, and sometimes you get a situation called fulminant colitis, where symptoms worsen rapidly, and the patient can show signs of toxicity.

That sounds intense. So, when we’re diagnosing, what’s the role of sigmoidoscopy?

In acute colitis, the diagnosis is made by sigmoidoscopy, where the mucosa will appear edematous, friable, and erosive. But if you suspect fulminant disease, you shouldn’t perform a colonoscopy because of the risk of perforation.

What about the Mayo endoscopic scoring system? How does that fit in?

The Mayo system is a standard way to assess disease activity. A score of 0 means normal or inactive colitis, 1 indicates erythema and decreased vascularity, 2 means friability, marked erythema, and erosions, and 3 signifies ulcerations, severe friability, and spontaneous bleeding. Mayo scores 1–2 usually point to mild to moderate disease, and scores 2–3 are seen in moderate to severe disease.

Got it. And what kind of imaging do we use?

For patients with severe colitis, we use plain radiographs or CT scans to check for significant colonic dilation.

What about the differential diagnoses? What else should we be thinking about?

We have to consider a few things: infectious colitis, CMV colitis, and in sexually active patients with proctitis, infections like gonorrhea, chlamydia, herpes, and syphilis. In older adults with cardiovascular disease, we also need to think about ischemic colitis and radiation proctitis in patients with history of radiation therapy. Don’t forget about Crohn’s disease, which can involve the colon as well.

Of course! So, once we’ve diagnosed ulcerative colitis, what are the treatment goals?

The main goals of treatment are:

To terminate the acute attack,

To achieve complete remission, and

To prevent recurrence.

So how do we treat mild to moderate ulcerative colitis?

Initially, we treat mild to moderate ulcerative colitis with topical mesalamine, which is the drug of choice. It can be used as a suppository for proctitis or as an enema for proctosigmoiditis. If the patient doesn’t respond, we can combine topical mesalamine with oral 5-ASA, add a topical corticosteroid, or use oral prednisone or budesonide along with both rectal and oral 5-ASA for about 4–8 weeks. Maintenance therapy with 5-ASA reduces relapse rates. Most patients who achieve remission should continue indefinitely to prevent relapse, though some may prefer intermittent therapy for relapses.

What if patients don’t improve after 4–8 weeks of 5-ASA therapy?

If they don’t improve, we can add oral corticosteroids like budesonide or prednisone. If they need corticosteroid therapy every 1–2 years for relapses, we should escalate to include thiopurines like azathioprine or mercaptopurine, or even biologic agents.

And for moderate to severe colitis, what’s the treatment plan?

For moderate to severe colitis, we typically use corticosteroids like prednisone or methylprednisolone. Prednisone is started at 40 mg daily, with rapid improvement seen in most cases within 2 weeks. After that, the dose is tapered by 5–10 mg per week. Once remission is achieved, patients should be maintained on oral mesalamine, and we sometimes add a thiopurine to to promote complete steroid withdrawal and maintain long-term remission.

What about biologic agents?

For biologic agents, we use anti-TNF antibodies like infliximab, adalimumab, and golimumab, as well as vedolizumab, ustekinumab, tofacitinib, upadacitinib, and ozanimod. For patients who are naïve to biologic therapy, infliximab or vedolizumab is usually the first-line treatment for moderate to severe colitis. If those don’t work, we can try ustekinumab or the small molecules like tofacitinib and upadacitinib.

What’s the deal with small molecules?

These offer oral administration and have favorable safety profiles. They might become first-line treatment for young, healthy patients with moderate to severe disease. But for older patients or those with cardiovascular disease, they’re more likely to remain second or third-line therapies—we need more data to confirm their long-term safety.

Now, in cases of severe and fulminant colitis, what do we do?

In severe cases, patients may be very ill, with symptoms like fever, hypovolemia, and abdominal distention. They might develop toxic megacolon, where the colon dilates over 6 cm on plain films and shows signs of toxicity. We should discontinue all oral intake for 24–48 hours, and start total parenteral nutrition if needed. Opioids and anticholinergics should be stopped. We focus on fluid resuscitation, electrolyte correction, and potentially transfusions for anemia.

And what about the risks of venous thromboembolism?

Absolutely—VTE prophylaxis should be given to all hospitalized patients with inflammatory bowel disease due to their increased risk. Surgery should be considered if the patient doesn’t improve within 48–72 hours.

What’s the role of surgery in ulcerative colitis?

Surgery is indicated in cases of severe hemorrhage, perforation, documented carcinoma, or fulminant colitis that doesn’t improve with treatment. It’s also an option for patients with refractory disease requiring long-term corticosteroids. The surgery of choice is a total proctocolectomy with ileostomy, which cures the disease. Many patients may resist this due to concerns about bowel function, self-image, and social interactions, though. After surgery, they may have a standard ileostomy, a continent ileostomy, or an internal ileal pouch–anal anastomosis (IPAA), which preserves intestinal continuity.

What happens after an ileal pouch surgery?

After IPAA, patients typically have about 5–7 loose bowel movements per day without incontinence. But over time, pouchitis can develop, causing increased stool frequency, fecal urgency, cramping, and bleeding. This can often be treated with a 2-week course of antibiotics like metronidazole or ciprofloxacin. For patients with frequent relapses of pouchitis, continuous antibiotics might be needed.

That’s a lot of ground covered! What about the cancer risk in these patients?

Patients with ulcerative colitis have an increased risk of developing colon carcinoma. So, colonoscopies should be done 8 years after diagnosis, and biopsies should be taken from any lesions during the procedure. The interval for subsequent colonoscopies depends on the extent and activity of the disease, as well as any signs of scarring, pseudopolyps, or dysplasia.

So, to summarize—ulcerative colitis requires a multi-pronged approach to treatment, with medications first and surgery as a last resort for severe cases, while maintaining vigilance for cancer risk.

Thanks for joining us on this deep dive into ulcerative colitis!

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