Diagnosis ulcerative colitis

The major diagnostic difficulty is to distinguish the first

attack of acute colitis from infection.

In general, diarrhoea lasting longer than 10 days in

Western countries is unlikely to be the result of infection.
A history of foreign travel, antibiotic exposure
(pseudomembranous colitis) or homosexual contact
suggests infection.
Stool microscopy, culture and examination for Clostridium
difficile toxin or for ova and cysts, sigmoidoscopy and
rectal biopsy, blood cultures and serological tests for
infection are useful.
 Diagnosis Crohn's disease
Crohn's disease can usually be diagnosed with confidence without
histological confirmation in the appropriate clinical setting.

Indium- or technetium-labelled white cell scanning may help

identify inflamed intestinal segments.

In atypical cases biopsy or surgical resection is necessary to exclude

other diseases. This can often be done endoscopically by ileal
intubation at colonoscopy, but sometimes laparotomy or
laparoscopy with resection or full-thickness biopsy is necessary.
Investigations
• Full blood count may show anaemia resulting from bleeding or
malabsorption of iron, folic acid or vitamin B12.
• Serum albumin concentration falls as a consequence of protein-
losing enteropathy, reflecting active and extensive disease, or
because of poor nutrition.
• The ESR is raised in exacerbations or because of abscess.
• Elevation of CRP concentration is helpful in monitoring Crohn's
disease activity.
• Bacteriology stool cultures
A straight abdominal X-ray is essential in the management of
patients who present with severe active disease. Dilatation of the
colon, mucosal oedema ('thumb-printing') or evidence of
perforation may be found.
In small bowel Crohn's disease there may be evidence of intestinal
obstruction or displacement of bowel loops by a mass.
Colonoscopy
may show active inflammation with pseudopolyps or a complicating
carcinoma
In ulcerative colitis the macroscopic and histological abnormalities are
confluent and most severe in the distal colon and rectum. Stricture
formation does not occur in the absence of a carcinoma.

In Crohn's colitis the endoscopic abnormalities are patchy, with

normal mucosa between the areas of abnormality. Aphthoid or
deeper ulcers and strictures are common
 Barium studies
Barium enema is a less sensitive
investigation than colonoscopy. In long-
standing ulcerative colitis the colon is
shortened and loses haustra to become
tubular, and pseudopolyps are seen

In Crohn's colitis a range of

abnormalities occur. The appearances
may be identical to those of ulcerative
colitis but skip lesions, strictures and
deeper ulcers are characteristic. Reflux
into the terminal ileum may show
stricture and ulcers.
Contrast studies of the small bowel are normal in ulcerative colitis, but
in Crohn's disease affected areas are narrowed and ulcerated; multiple
strictures are common
Management

TREATEMENT ALGORITHIM OF UC
TREATEMENT ALGORITHIM OF CROHNS
MEDICAL MANAGEMENT OF FULMINANT ULCERATIVE COLITIS
• Intravenous fluids
• Transfusion if Hb < 100 g/l
• I.v. methylprednisolone (60 mg daily) or hydrocortisone
• Antibiotics for proven infection
• Nutritional support
• Subcutaneous heparin for prophylaxis of venous
thromboembolism
• Avoidance of opiates and antidiarrhoeal agents
• I.v. ciclosporin (2 mg/kg) or infliximab (5 mg/kg) in stable
patients not responding to 3-5 days of corticosteroids
INDICATIONS FOR SURGERY IN ULCERATIVE COLITIS
Impaired quality of life
• Loss of occupation or education
• Disruption of family life
Failure of medical therapy
• Dependence upon oral corticosteroids
• Complications of drug therapy
Fulminant colitis
Disease complications unresponsive to medical therapy
• Arthritis
• Pyoderma gangrenosum
Colon cancer or severe dysplasia
 COMPARISON OF ULCERATIVE COLITIS AND CROHN'S DISEASE
Ulcerative colitis Crohn's disease
Age group Any Any
Gender M = F M = F
Ethnic group Any Any; more common in
Ashkenazi Jews
Genetic factors HLA-DR103 associated CARD 15/NOD-2
with severe disease mutations predispose
Risk factors More common in non- More common in smokers
/ex-smokers
Appendicectomy protects
Anatomical Colon only; begins at Any part of gastrointestinal
distribution anorectal margin with tract; perianal disease
variable proximal common; patchy
extension distribution-'skip lesions'
Extraintestinal Common Common
manifestations
Presentation Bloody diarrhoea Variable; pain, diarrhoea,
weight loss all common
Histology Inflammation limited to Submucosal or transmural
mucosa; crypt distortion, inflammation common;
cryptitis, crypt abscesses, deep fissuring ulcers,
loss of goblet cells fistulae; patchy changes;
granulomas
Management 5-ASA; corticosteroids; Corticosteroids;
azathioprine; colectomy is azathioprine; methotrexate;
curative infliximab; nutritional
therapy; surgery for
complications is not
curative