A synopsis of AFP's "Ulcerative Colitis"

A synopsis of:
Ulcerative Colitis, STEPHEN M. ADAMS, MD, University of Tennessee College of Medicine, Chattanooga, Tennessee, PAUL H. BORNEMANN, MAJ, MC, USA, Tripler Army Medical Center Family Medicine Residency Program, Honolulu, Hawaii
Am Fam Physician. 2013 May 15;87(10):699-705.
http://www.aafp.org/afp/2013/0515/p699.pdf

    Ulcerative colitis (UC) is inflammation of the colonic mucosa. If it affects the entire colon, it is referred to as pancolitis. Symptoms of UC consist of hematochezia, diarrhea, and abdominal pain. The onset can be gradual or sudden. Extraintestinal manifestations such as arthritis, uveitis, AS, psoriasis, and erythema nodosum can occur in up to a third of patients. Smoking or having had an appendectomy have a protective effect. Those with a previous infection from Salmonella or Campylobacter have a 10x higher chance of developing UC. A diet high in sugar, fat and meat have an increased risk. A diet rich in vegetables have a lower risk. People also say that living in such a "sterile" society (the hygiene hypothesis) decreases exposure to "bacterial and helminth antigens", which makes our immune system more open to illness such as UC. 
     Endoscopic biopsy will give a definitive diagnosis. P-ANCA and ASCA (anti-Saccharomyces cerevisiae antibodies) will be positive in UC.  Fecal calprotectin and lactoferrin are sensitive tests, but they may delay diagnosis. The difference between UC and Crohn's disease is that inflammation from UC is limited to the colonic mucosa, whereas in Crohn's, the inflammation can be anywhere. UC is a contiguous inflammation, crohns has unaffected areas of mucosa between diseased areas (skip lesions). Other diseases to rule out include dysentery, bacterial and C. diff colitis, ischemic colitis, and microscopic colitis. Biopsy will tweeze out most of these diseases. 
      Treatment is based on severity of the disease. The goal is to induce remission and prevent relapse. If the disease is distal to the colon, 5-ASA enemas can be used for 4-6 weeks. Suppositories are preferred in proctitis. Oral 5-ASA can be considered if remission does not occur, or if the colitis is more extensive than just distally. At this point, the patient can be maintained on their current medication if remission occurs. If the disease is ongoing, oral steroids may be tried for 4-6 weeks. If remission occurs now, the patient can be maintained on azathioprine. If remission has not occurred, infliximab can be started.  If the disease is still continuing, the patient may try IV steroids, cyclosporine, or a colectomy. Those who present with severe or fulminant colitis should be admitted and started on a 3-5 day regimen of IV steroids. Transition to azathioprine can happen it remission occurs at this point. If not, the patient can be given a trial of cyclosporine or infliximab. Colectomy can be considered at this point as well.  Probiotics (lactobacillus or E. coli/mutaflor) have been shown to be as effective as 5-ASA maintenance therapy.
     UC can increase rates of osteoporosis, colorectal cancer, and abnormal pap smears.