Ulcerative colitis

Ulcerative colitis (nonspecific ulcerative colitis, ulcerative colitis, idiopathic colitis) is a chronic inflammatory disease with ulcerative-destructive changes in the mucous membrane of the rectum and colon, characterized by a progressive course and complications.

the article about the treatment of ulcerative colitis .

Reasons for the development of the disease

Numerous studies show that the peak incidence of UC occurs at the age of 15-40 years, although people of any age can get sick. However, the incidence before the age of 15 is observed in only 10-15% of people, and manifestations of the disease after 40 years are extremely rare.

At different times, many theories of the occurrence of ulcerative colitis have been put forward. It was believed that the disease was caused by bacteria, viruses, and cytoplasmic toxins. Immune disorders in patients with ulcerative colitis have been studied especially deeply.

The exact causes of the disease are still unknown. There are many theories explaining the reasons for its development:

• infectious;
• enzymatic;
• allergic;
• immune;
• neurogenic;
• genetic.

But none of these theories has been proven to be decisive. It is currently believed that all of these factors are involved to varying degrees in the development of ulcerative colitis.

In the early 80s of the twentieth century, sensational reports appeared about the connection between smoking and the development of inflammatory bowel diseases. The incidence of UC in smokers is significantly lower than in people who do not smoke or have quit smoking.

The risk of developing Crohn's disease , on the contrary, is increased by 1.33 times in smokers.

Some authors associate the occurrence of UC and CD in women with the use of contraceptives.

Many researchers associate the development of these diseases with diet. First of all, this is the consumption of a large amount of refined foods against the background of a deficiency of dietary fiber. There are opinions that some fats, in particular margarine, cause the development of UC and CD.

How does the disease affect the condition of the intestines?

The pathological process of ulcerative colitis begins in the rectum and spreads, affecting the overlying parts of the intestine. Sometimes it affects the entire colon and part of the ileum .

The intestinal epithelium, which normally renews itself quickly, loses this property in UC. Even during the period of remission, manifestations of inflammation and reduced regeneration persist in the intestinal mucosa.

Inflammation can spread:

• on the rectum ( proctitis );
• to the sigmoid colon (proctosigmoid);
• on the entire left side (left-sided colitis);
• throughout the entire colon (total colitis).

In 18-30% of cases, ulcerative colitis can affect part of the ileum and appendix (ileocolitis).

With this disease, the length of the large intestine decreases by about 1/3. The mucous membrane swells, thickening of the folds is observed.

Ulcers of various sizes and irregular shapes form in the mucous membrane. Characteristic are narrow, long ulcers located along the muscle fibers in two or three parallel rows.

In severe cases, the mucous membrane is destroyed throughout, and the surface of the affected area of ​​the intestine takes on the appearance of an extensive bleeding ulcer.

With a long chronic course of the disease against the background of ulcers, pseudopolyps are formed, which are either preserved areas of the mucosa or foci of its hyperplasia.

If the epithelium of the crypts is affected, then they talk about cryptitis. It is accompanied by copious mucus secretion and depletion of goblet cells. This creates difficulties in diagnosis, since this form is similar to infectious colitis.

And only with the development of the process and the opening of several crypt-abscesses, large ulcerations are formed, which can be identified during endoscopic examination.

During the period of remission, the mucous membrane is restored, but atrophy, thickening and deformation of the crypts persist.

When the mucous membrane is affected over a significant area and is unable to absorb water, diarrhea develops.

Bleeding is the result of ulceration of the mucous membrane, overflow of the vessels of the mucous membrane of the colon with blood and the development of loose granulation tissue, well supplied with blood vessels.

Fistulas, intestinal obstruction and perforation are rare in ulcerative colitis.

Symptoms

Nonspecific ulcerative colitis is characterized by three main symptoms:

• discharge of blood during bowel movements;
• intestinal dysfunction;
• stomach ache.

Discharge of blood during bowel movements

This sign is the main and often the first manifestation of the disease.

Blood can be released in the stool, mixed with mucus and pus, or in its pure form.

When the rectum is affected, it is found on the surface of the stool, which is sometimes mistakenly regarded as hemorrhoids. When localized in other parts of the intestine, the blood appears mixed with feces. Its amount varies widely from streaks to 300 ml or more with each act of defecation.

In the acute form of the disease, blood is released in a stream. In this case, a decrease in blood pressure is possible up to the development of collapse and hemorrhagic shock.

Bowel dysfunction

The second important syndrome that always manifests itself in UC. Most patients complain of frequent, unstable stools.

Diarrhea has the following characteristics:

• from loose stools with a frequency of 3-4 times a day to constant watery non-fecal discharge;
• typical occurrence of diarrhea at night;
• tenesmus (false urge to defecate);
• scarlet blood in stool;
• mucus in stool.

Patients with proctitis and sigmoiditis often experience constipation. This is caused by retention of intestinal contents in the upper sections and their rapid evacuation through the zone of active inflammation. As a result of stool retention, false urges appear with the release of mucus and blood.

Abdominal pain

Most often, with ulcerative colitis, patients complain of pain in the lower abdomen.

• The pain is constant or cramping in nature,
• most often localized in the left iliac region (lower left abdomen),
• worsens before defecation,
• disappears after it.

When palpating the abdomen, defence (protective tension of the abdominal wall muscles) may appear.

With toxic dilatation (expansion) of the colon, abdominal pain is constant with the appearance of peritoneal irritation syndrome.

Disease severity

Depending on the intensity of its manifestations, ulcerative colitis can occur in the following forms:

• light;
• moderate;
• severe;
• lightning fast;
• chronic.

Symptoms of forms of ulcerative colitis of varying severity

Form of the disease	Symptoms
Lightweight	Pasty stool <5 times a day, slight admixture of blood and mucus in the stool, absence of fever, tachycardia, anemia, general condition is satisfactory, ESR <30 mm/h
Moderate	Loose stools 5-8 times a day, blood and mucus in the stool, fever > 37.5, tachycardia, anemia, general condition is satisfactory.
Heavy	Bloody stools > 6 times a day, ESR > 30 mm/h, fever > 38.5, pulse rate > 90 beats/min, blood hemoglobin < 10.5 g/dl.

Mild course of UC

Symptoms of mild ulcerative colitis:

• satisfactory condition of the patient;
• abdominal pain is moderate and short-lived;
• formed, frequent stools up to 2-3 times a day;
• Blood and mucus periodically appear in the stool.

As a rule, the inflammatory process is limited to the area of ​​the rectum and sigmoid colon.

There are no systemic manifestations such as

• fever;
• weight loss;
• intoxication.

The course of the disease is characterized by periods of exacerbations and remissions. Exacerbations occur no more than 2 times a year. Remissions can be long, more than 2-3 years.

The effect of treatment with salazal preparations is satisfactory.

Moderate course of the disease

• The main symptom is the presence of diarrhea in patients.
• Stools are frequent, 6-8 times a day, mixed with blood and mucus.
• Severe cramping pain in the abdomen.
• Fever with a rise in temperature to 38⁰C.
• Great general weakness.

Extraintestinal signs of the disease (arthritis, uveitis, erythema nodosum) may also appear.

The disease progresses with constant exacerbations, the effect of treatment with salazal preparations is unstable. During exacerbations, hormones are prescribed.

Severe form

The fulminant course of ulcerative colitis is characterized by an acute onset. Rapidly (within several weeks) a total lesion of the colon develops with the spread of the pathological process deep into the intestinal wall. The patient's condition deteriorates sharply.

The main symptoms are:

• sudden onset;
• high fever > 38⁰C;
• profuse diarrhea up to 24 times a day;
• heavy intestinal bleeding;
• rapid increase in dehydration;
• expansion of the colon more than 6 cm;
• tachycardia;
• decreased blood pressure;
• increase in extraintestinal manifestations.

Conservative treatment with steroid drugs is not always effective; urgent surgical treatment is often required.

Chronic ulcerative colitis

As the disease progresses, in some cases, dystrophy and atrophy of the small intestinal mucosa, malabsorption, leading to decreased immunity and the development of small intestinal dysbiosis develop.

Complications

Complications of UC are divided into local and general (systemic).

Local ones include:

• perforation;
• toxic dilatation (toxic megacolon);
• intestinal bleeding;
• strictures of the rectum and colon;
• paraproctitis;
• fistulas;
• cracks;
• perianal skin irritation;
• colon cancer.

Systemic complications are associated with a combination of local complications or extraintestinal manifestations.
They occur in a significant proportion of patients with severe UC. Most of them are autoimmune in nature and are associated with damage to the skin, eyes, joints and spine.

Diagnostics

The diagnosis of UC is made on the basis of a comprehensive study:

• clinical;
• endoscopic;
• X-ray;
• morphological.

Clinical examination

During a clinical examination, various variants of the course of the disease may be encountered: from asymptomatic to severe with symptoms of peritonitis.

Digital examination of the rectum, the presence of cracks and lumpy mucosa, blood and pus on a rubber glove is of great diagnostic importance.

In clinical blood tests, even in mild forms, slight leukocytosis and an increase in ESR are detected. As the severity of the disease increases, anemia of mixed origin occurs (B₁₂-deficiency and iron deficiency), and the ESR increases significantly. Hyperleukocytosis indicates the occurrence of complications.

Microbiological examination of stool in patients with ulcerative colitis reveals dysbiosis of varying severity.

Sigmoidoscopy

Sigmoidoscopy is often used as a primary examination .

Light form	average severity	Severe form
Diffuse erythema	Granularity of the mucosa	Intense inflammation
Lack of vascular pattern	Petechial hemorrhages	Purulent exudate
Contact bleeding	Spontaneous bleeding	Multiple ulcerations

X-ray

The role of this study in recognizing this pathology is extremely important.
Fluoroscopy allows you to determine:

• extent of the lesion;
• clarify the diagnosis;
• carry out differential diagnosis with Crohn's disease, diverticular disease and ischemic colitis;
• promptly identify signs of malignancy (degeneration of cells into malignant ones).

During exacerbations, when irrigoscopy and colonoscopy are prohibited, a survey X-ray examination of the abdominal cavity is especially important.

Plain radiographs may reveal:

• shortening of the intestine;
• lack of haustration;
• toxic dilatation;
• free gas under the diaphragm dome during perforation.

If it is necessary to examine the overlying parts of the colon, irrigoscopy with the double contrast method .

However, irrigoscopy, like colonoscopy, should be carried out with great caution, since in the acute form they can complicate the course of the disease.

Differential diagnosis

First of all, it is necessary to conduct a study for the presence of intestinal infection .

It can be more difficult to distinguish between ulcerative colitis and Crohn's disease. If the examination results do not clearly distinguish between UC and CD, then a diagnosis of indeterminate colitis is made. This situation occurs in 5-10% of patients; surgical treatment is indicated for them.

What is the difference between UC and CD?

Symptoms and research results	UC	BC
Blood in stool	80-85 %	35-40 %
Abdominal pain	Not expressed, quite rare	Occurs frequently
Weight loss	Not typical	Characteristic
Fissures, fistulas and other perianal manifestations	20% of cases	80% of cases
Internal fistulas	Rarely	30 %
Length of lesion	Continuous damage to the entire colon	Segmental damage, inflammation can spread from the mouth to the anus
Intestinal obstruction	Not typical	Characteristic
Type of mucosa	Pseudopolyps, deep, undermined ulcers affecting the mucosa and submucosa	Individual ulcers penetrating the muscularis and serosa, cobblestones, fistulas
Serosa	Normal	Fat pendants are often welded together
Gut length	Shortens	Normal
Benign scar strictures	Rarely	Often
Depth of lesion	Mucosal and submucosal layer	The entire intestinal wall
Ulcers	Wide and deep	Superficial
"Cut" cracks	Rarely	Often
Granulomas	No	Always

Sometimes it becomes necessary to distinguish between UC and intestinal tuberculosis.
The diagnosis of intestinal tuberculosis is confirmed bacteriologically and histologically.

Pseudopolyposis in ulcerative colitis can be mistaken for intestinal polyposis. Histological examination makes it possible to establish a diagnosis.

In elderly and senile people, UC should be differentiated from ischemic colitis. Ischemic colitis is characterized by intense, paroxysmal abdominal pain 20-30 minutes after eating, while with ulcerative colitis the pain increases before defecation. X-ray examination can also clarify the diagnosis.

In UC with dysplasia of the epithelium of the colon mucosa and/or colorectal cancer, the expression of 699 genes is disrupted, the identification of which can be an early diagnostic and prognostic sign of its development. Early diagnosis becomes especially important 10 years after the onset of the disease.

Treatment

First of all, the patient is prescribed an adequate regimen that provides physical and mental rest. As the inflammatory phenomena subside, a gradual increase in physical activity is possible.

It is also necessary to adhere to a diet. Food should contain an increased amount of protein and consist of mechanically gentle dishes that do not contain laxatives.

Treatment includes medications, detoxification of the body, and in severe cases, surgery.

You can read more about the treatment of ulcerative colitis in the article “Treatment of ulcerative colitis” .

When should you go to the hospital?

There is no reason for hospitalization (treatment is carried out on an outpatient basis) if:

• appetite is maintained;
• There is no pain on palpation of the abdomen;
• The blood test was unchanged.

Hospitalization is indicated if:

• diarrhea;
• discharge of scarlet blood from the rectum;
• fever;
• intoxication.

Absolute indicators for emergency hospitalization are:

• diarrhea more than 10 times a day;
• abdominal pain on palpation;
• intestinal paresis;
• fever;
• tachycardia;
• anemia (externally expressed by pallor of the skin and mucous membranes);
• leukocytosis.

Prognosis for UC

What the results of treatment will be and how much ulcerative colitis interferes with normal life depends on the form of the disease.

In severe cases and the presence of extraintestinal manifestations, the prognosis may be unfavorable. Studies show that about 20% of patients undergo colectomy; every fourth patient has only one episode of the disease throughout his life. 40% experience annual remission in the first years; from the second to the fourth year, every second person experiences a relapse of the disease annually.

With mild and moderate forms, the prognosis is favorable. Patients should be transferred to light work.

Prevention

During the period of remission, it is recommended to take salazal preparations and bacterial preparations.

Great importance is attached to proper nutrition.

You should try to avoid stressful situations.

Patients suffering from UC for more than 5-7 years are recommended to have a colonoscopy with targeted biopsy annually, during periods of remission.