Ulcerative colitis will present as → a 32-year-old woman comes to your office with a 6-month history of loose bowel movements, approximately eight per day. Blood has been present in many of them. She has lost 30 pounds. For the past 6 weeks, she has had an intermittent fever. She has had no previous gastrointestinal (GI) problems, and there is no family history of GI problems. On examination, the patient looks ill. Her blood pressure is 130/ 70 mm Hg. Her pulse is 108 beats/ minute and regular. There is generalized abdominal tenderness with no rebound. A sigmoidoscopy reveals a friable rectal mucosa with multiple bleeding points.
Crohn's disease will present as → a 25-year-old man with an 18-month history of chronic abdominal pain. The patient has seen several physicians and has been diagnosed as having “nervous stomach,” irritable bowel syndrome, and “depression.” Associated with this abdominal pain for the past 3 months have been nonbloody diarrhea, anorexia, and a weight loss of 20 pounds. He has developed a painful area around the anus. On examination, the patient has diffuse abdominal tenderness. He looks thin and unwell. He has a tender, erythematous area in the right perirectal area.
Ulcerative Colitis (“colitis” = confined to colon)
- Presents with bloody puss filled diarrhea, rectal/lower quadrant pain, fever, and urgency
- Inflammation isolated to colon and confined to mucosa and submucosa (unlike Crohn's not transmural)
- Most common site is rectum
- Bimodal distribution of peak onset: age 15-25 and age 55-65
- Labs: ↑ WBC, ESR, and anemia
- Diagnosis by barium enema LEAD PIPE APPEARANCE and colonoscopy with biopsy both show continuous inflammation starting from rectum and extending proximally with loss of haustral markings and lumen narrowing
- Complications: Toxic megacolon, colorectal cancer
- Antibody test: Antineutrophil cytoplasmic antibodies (pANCA)
- Presents with abdominal pain, weight loss, diarrhea and oral mucosal aphthous ulcers. Longer standing disease may have severe anemia, polyarthralgia, and fatigue.
- Most common site is the terminal ileum
- Distribution from mouth to anus and will commonly present with thickened bowel wall, cobblestoning and “skip” lesions
- Linear fissures and cobblestone appearance. Tends to be transmural while UC is limited to the mucosa and submucosa
- Complications include strictures identified by a STRING SIGN on barium study
- Presents with abdominal pain, weight loss, diarrhea and oral mucosal aphthous ulcers
- Obstruction, abscess, fistula, and sinus tracts are common
- 1-3% cancer risk (low)
- Antibody test: +Anti-Saccharomyces cerevisiae antibodies (ASCA)
- Barium x-rays of the stomach, small bowel, and colon
- Abdominal CT
- Sometimes magnetic resonance (MR) enterography, upper endoscopy, and/or colonoscopy
Sigmoidoscopy with biopsy
Laboratory tests should be done to screen for anemia, hypoalbuminemia, and electrolyte abnormalities. Liver function tests should be done; elevated alkaline phosphatase and γ–glutamyl transpeptidase levels in patients with major colonic involvement suggest possible primary sclerosing cholangitis. Leukocytosis or increased levels of acute-phase reactants (eg, ESR, C-reactive protein) are nonspecific but may be used serially to monitor disease activity. To detect nutritional deficiencies, levels of vitamin D and B 12 should be checked every 1 to 2 yr.
Treatment for UC and Crohn's disease are the same
- This is useful if the colon is involved. 5-ASA (mesalamine) is the active compound and is released in the colon—it is more useful in UC than in Crohn disease.
- 5-ASA compounds block prostaglandin release and serve to reduce inflammation.
- There are preparations of 5-ASA that are more useful in distal small bowel disease.
- Metronidazole—if no response to 5-ASA
- Systemic corticosteroids (prednisone)—for acute exacerbations and if no response to metronidazole
- Immunosuppressants (azathioprine, 6-mercaptopurine)—in conjunction with steroids if the patient does not respond to above agents
- Bile acid sequestrants (cholestyramine or colestipol)—for patients with terminal ileal disease who cannot absorb bile acids
- Antidiarrheal agents generally not a good choice (may cause ileus)
- Nutritional supplementation and support—parenteral nutrition is sometimes necessary
- Surgical UC — often curative (unlike Crohn disease) and involves total colectomy.
- Surgical Crohn's (eventually required in most patients) - Involves segmental resection of involved bowel Disease recurrence after surgery is high—up to 50% of patients experience disease recurrence at 10 years postoperatively
Glucocorticoids are used in moderate to severe inflammatory bowel disease.
Metronidazole may have a role in Crohn's disease after ileal resection but has no role in the treatment of mild to moderate disease.
Azathioprine is used in severe, glucocorticoid-dependent inflammatory bowel disease.
See D for explanation
See D for explanation
See D for explanation
Ulcerative colitis is more common in non-smokers and ex-smokers.
Smoking is protective in UC, with a lower incidence of disease in smokers and current smoking protects against UC and, after onset of the disease, improves its course, reducing the need for colectomy.
Appendectomy protects against ulcerative colitis.
Appendectomy is a protective factor against UC.
Crohn disease causes segmental transmural inflammation of the bowel.
Distribution from mouth to anus and will commonly present with thickened bowel wall, segmental transmural inflammation of the bowel, cobblestoning and “skip” lesions.
Ulcerative colitis affects the colon in a descending fashion.
An anti-TNF antibodies. Suppress inflammation and induce apoptosis of inflammatory cells.
Budesonide is a potent corticosteroid and has an anti-inflammatory effect.
Mercaptopurine is a Thiopurine. It is an immunomodulator which acts by inducing T-cell apoptosis.
Inflammation limited to the superficial layer of the bowel wall
Crohn’s disease is characterized by a transmural inflammation of the GI tract.
The affinity to involve the rectosigmoid junction
It may affect any part of the GI tract but is usually associated with the terminal ileum, the colon, or both.
Decreased risk of colon cancer
There is also an increased risk— five times the average— for bowel cancer.
Continuous mucosal areas of ulceration that affect the anus
This is the description of ulcerative colitis