Siddharth Singh Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, CA, USA Ulcerative colitis is a chronic idiopathic inflammatory disease of the colon, most commonly affecting adults in their third to fourth decades of life. Patients usually present with bloody diarrhea and urgency of defecation, and the disease is diagnosed based on colonoscopy and histological findings, with characteristic findings. It is typically characterized by a lifelong relapsing and remitting course, with mucosal inflammation starting in the rectum and extending continuously to proximal segments of the colon. In patients affected with this disease, goals of therapy are to achieve and maintain clinical remission, maintain good quality of life, minimize risk of disease‐related complications (such as relapse, surgery, colorectal cancer, etc.), while balancing risk of treatment‐related complications, especially those associated with immunosuppressive therapy. Options for medical management, especially for moderate to severe disease, are rapidly evolving with the advent of targeted immunosuppressive agents. Unfortunately, there is no cure for the disease, and approximately 15% patients may require colectomy for medically refractory disease or colorectal cancer. Figure 29.1 Examples of endoscopic UC activity. (a) Normal vascular pattern, no erythema, no friability, no ulcers or spontaneous bleeding (Mayo Endoscopic Score [MES] = 0). (b) Patchy blurring of the vascular pattern, erythema (MES = 1). (c) Friable mucosa, complete loss of the vascular pattern, erosions (MES = 2). (d) Large ulcerations, spontaneous bleeding (MES = 3). Source: Source: Khanna R., Ma C., Jairath V., Vande Casteele N., Zou G., Feagan B.G. Endoscopic assessment of inflammatory bowel disease activity in clinical trials. Clin Gastroenterol Hepatol 2020:S1542‐3565(20)31674‐8. Reproduced with permission of Elsevier. Figure 29.2 Endoscopic assessment of disease activity in ulcerative colitis, based on the UC Endoscopic Index of Severity and modified Mayo Endoscopy Score. Source: Rubin D.T., Ananthakrishnan A.N., Siegel C.A., Sauer B.G., Long M.D. ACG Clinical Guideline: Ulcerative Colitis in Adults. Am J Gastroenterol 2019;114(3):384–413. Reproduced with permission of Wolters Kluwer Health. Figure 29.3 Chromoendoscopy facilitates visualization of nonpolypoid colorectal neoplasia. (a) The lesion was difficult to appreciate with high‐definition white‐light endoscopy. A possible flat lesion was noted retrospectively, as shown by the white arrowheads. (b) The patient presented for follow‐up 6 months later. A possible superficial elevated lesion was noted (blue arrowheads). (c) After application of dilute indigo carmine, the lesion and its borders were easily detected. Source: Soetikno R., Sanduleanu S., Kaltenbach T. An atlas of the nonpolypoid colorectal neoplasms in inflammatory bowel disease. Gastrointest Endosc Clin North Am 2014;24(3):483–520. Reproduced with permission of Elsevier. Figure 29.4 Signs of nonpolypoid colorectal neoplasia in IBD. The detection of flat and depressed neoplasms in colitic IBD, unlike the detection of polypoid neoplasms, relies primarily on the recognition of subtle changes in the mucosa. The subtle findings require constant awareness by the endoscopist for areas that appear to be slightly different from the background in color, pattern, or level. (a) Nonpolypoid lesions typically have a slightly elevated appearance that can often be recognized by a deformity on the colon wall (arrows). (b) Occasionally, there may be spontaneous hemorrhage on the surface. The surface may be friable. (c) Obscure vascular pattern or (d) increased erythema (within circle) may suggest a lesion is present, in that these lesions may disturb the mucosal vascular network. The surface pattern may show (e) villous features or (f) irregular nodularity (arrow). Source: Soetikno R., Sanduleanu S., Kaltenbach T. An atlas of the nonpolypoid colorectal neoplasms in inflammatory bowel disease. Gastrointest Endosc Clin North Am 2014;24(3):483–520. Reproduced with permission of Elsevier. Figure 29.5 The major variants of superficial neoplastic lesions in the colon and rectum. Superficial colorectal neoplasms in patients with IBD can be described. Lesions are classified as protruding (polypoid) and nonprotruding (nonpolypoid). Polypoid neoplasms may be further divided into pedunculated (0‐Ip) or sessile (0‐Is). Nonpolypoid lesions can be divided into slightly elevated/table top (IIa), depressed (IIc), or completely flat (IIb). Source: Soetikno R., Sanduleanu S., Kaltenbach T. An atlas of the nonpolypoid colorectal neoplasms in inflammatory bowel disease. Gastrointest Endosc Clin North Am 2014;24(3):483–520. Reproduced with permission of Elsevier. Figure 29.6 Inflammatory pseudopolyps in patients with ulcerative colitis, on surgical specimen. Source: Pathorama.ch.
CHAPTER 29
Ulcerative colitis : clinical manifestations and management
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