ulcerative colitis
TRANSCRIPT
BACKGROUND
Figure 1: Major Type of IBD(Kumar, et al., 2007)
BACKGROUND
Ulcerative Colitis:
was first described in the mid-1800s
incidence is 1.2-20.3 per 100.000 person/year >> than
CD
most common form of IBD in adults
linked to smoking, diets high in fat and sugar,
medication, stress, and high socioeconomic status
incidence is in Europe and America and lowest in Asia
frequency in developed countries has been increasing
Only few articles discuss about UC
OBJECTIVE
To review the current understanding of the
pathophysiology, diagnosis, and treatment of
ulcerative colitis to date
PATHOGENESIS
Genetic factors
Microbiologic
factors
Mucosal immune
response
Epithelial
dysfunction and
autoimmunity
CLINICAL FEATURES
Mucosal inflammation, commencing in the rectum
(proctitis) and spreading proximally to the colon
Bloody diarrhea with or without mucus
Gradual onset, often followed by periods of
spontaneous remission and subsequent relapses
(chronic-exacerbation-remission)
Fecal urgency, tenesmus, constipation, abdominal
pain, fever, malaise, weight loss may occur
EXTRAINTESTINAL MANIFESTATION
COMPLICATION
DIAGNOSTIC
Endoscopic*
Biopsy*
ultrasonographic
radiologic
ENDOSCOPIC
Colonoscopy
Uniformly inflamed mucosa that starts at the
anorectal verge and extends proximally with an
abrupt or a gradual transition from affected to
normal mucosa
Mild Ulcerative Colitis (UC)
Mucosa has a granular
Erythematous appearance
Friability
Loss of the vascular pattern
Moderate UC :Erosions or microulcerations
Severe UC : shallow ulcerations with spontaneous
bleeding
Differentiate UC from CD : Rectal sparing, aphthous
ulcers, skip lesions, a cobblestone pattern, longitudinal
and irregular ulcers
ENDOSCOPIC
HISTOLOGIC EVALUATION
Inflammation restricted to the mucosal layer
Infiltrates consist primarily of lymphocytes, plasma
cells, granulocytes
Goblet cell depletion
Distorted crypt architecture
Epitheloid granuloma are not present : typical of CD
Epithelial dysplasia
No exact criteria for diagnosis of UC : but the
presence of 2 or 3 histologic feature above will suffice
LABORATORY TEST
Helpful in assessing and monitoring disease activity
and differentiating UC from other form of colitis
CBC
Fecal lactoferrin or calprotectin ->severity
Stool cultures for Clostridium difficile,
campylobacter species, Escherichia coli
Histologic, immunochemical, serologic, culture,
DNA testing -> rule out CMV infection
ASCA and pANCA (differentiate UC, CD, IC)
MEDICAL THERAPY
Level of clinical activity
Mild, moderate, or severe
Extent of disease
Proctitis, left-sided disease, extensive disease, or
pancolitis
Course of disease during FU
Patients preferences
PROCTITIS
• Mild to moderate: given for 2 weeks and can be
repeated : Mesalamine supp 1 g/d or enema 2-4 g/d
• If fails : hydrocortisone 100mg/d are a next step
No response to rectally : oral glucocorticoids
(Prednisone up to 40 mg/d)
LEFT SIDED COLITIS TO EXTENSIVE UC
Combination of oral and rectal 5-aminosalicylate up to
4,8 g/d
A once daily dose of 5-aminosalycilate :2 g/d
Oral glucocorticoid or immunosuppressive agents
(azathioprine or 6-mercaptopurine)
I.V glucocorticoid : 5-7 days
Monoclonal antibody against TNF-alfa: infliximab
5mg/kg of body weight at 0,2, and 6 weeks
MAINTENANCE OF REMMISION
Oral and rectal 5-aminosalicylate
Azathioprine 2,5mg/kg body weight 6-mercaptopurine 1,5 mg/kg body weight
Anti TNF-alfa : infliximab
Respond to probiotic therapy : VSL#3
SURGICAL TREATMENT
Reported Colectomy : <5% - >20% patients with UC
Surgery can be curative
Indication for surgery : Failure of medical therapy
Intractable fulminant colitis
Toxic megacolon
Perforation
Uncontrollable bleeding
Intolerable side effects of medications
Stricture
Uresectable high grade or multifocal dysplasia
Dysplasia-associated lession or masses
Cancer
Growth retardation in children
SURGICAL TREATMENT
Possible complication of surgery:
Small-bowel obstruction
Fistulas
Persistent pain
Sexual and bladder dysfunction
infertility
Total proctolectomy with ileal pouch-anal
anastomosis (IPAA) *
Complication : pouchitis (40%)
Symptoms : increased stool frequency, urgency,
incontinence, seepage, abdominal and perianal discomfort
FUTURE IMPLICATIONS
Figure 2. Agents for Which Evidence of Therapeutic Eff icacy in Ulcerative Colitis is Established or Preliminary
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