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Ulcerative colitis is an inflammatory bowel disease likely due to an autoimmune process. In North America, the prevalence of this disease is 1 per 1000, with a bimodal distribution of age of onset in the second and sixth decade of life [1].

The gastrointestinal (GI) symptoms include [1, 2]:

  • Intermittent diarrhea mixed with blood and mucous, more than ten episodes per day in severe disease

  • Intermittent rectal bleeding

  • Tenesmus

  • Abdominal cramping

The most common clinical signs and findings are [1, 2]:

  • Initially limited to rectum/distal colon in 33%, extending proximally to the left colon in 33%, pancolitis in the remaining 33%

  • Fevers to 39.5 °C in severe disease

  • Anemia requiring transfusion

  • Macro-ulcerations

  • Pseudopolyps

  • Oral aphthous ulcers

  • Iritis, uveitis, episcleritis

  • Seronegative arthritis, sacroiliitis

  • Erythema nodosum, pyoderma gangrenosum

  • Primary sclerosing cholangitis

The pathogenesis is not entirely clear but possibilities include [1, 2]:

  • Likely components of autoimmune disease, and genetics

  • Stress and environmental contributions

The pathology of mucosal biopsies can show [1, 3]:

  • Gross: continuous colonic involvement with ulceration (see Fig. 49.1), loss of vascular markings, petechiae, exudates, friability, and hemorrhage

  • Histological: distorted crypt architecture, crypt abscesses, cryptitis (see Fig. 49.2), inflammatory cells in the lamina propria

Fig. 49.1
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An endoscopic view of showing multiple colonic mucosal ulcers in a patient with active ulcerative colitis

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Fig. 49.2
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A photomicrograph of a colonic mucosal biopsy from a patient with active ulcerative colitis. The increased edema and damage to the walls of the crypts (arrow on the right) as well as crypt abscesses seen as collections of inflammatory cells within crypts (right arrow). Hematoxylin and eosin; high power

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The diagnosis is made with a combination of [1–4]:

  • Established with history and endoscopic findings

  • Confirmed with histology on colonic biopsy

  • Complete blood count, electrolytes, erythrocyte sedimentation rate, C-reactive protein, liver function tests

  • Stool culture

The differential diagnosis of ulcerative colitis should include [1–4]:

  • Crohn’s disease

  • Radiation colitis

  • Ischemic colitis

  • Infectious etiologies including Escherichia coli, Shigella, Campylobacter, Salmonella, and sexually transmitted diseases

Medical therapy does not cure the condition but offers symptomatic and ameliorative relief and includes [1–4]:

  • 5-aminosalicylic acid rectally and/or orally

  • Rectal steroids, oral steroids if no response

  • Azathioprine, 6-mercaptopurine

  • Infliximab, cyclosporine

Colectomy in steroid refractory disease offers definitive cure of the disease.