Video Endoscopic Sequence 1 of 7.

Endoscopy of Pancolitis. The entire colon is affected.

This is the case of a patient with long standing ulcerative colitis, male 37 year-old.

 UC is marked by diffuse, superficial inflammation of the
 colonic mucosa, beginning in the rectum and extending
 proximally to involve any contiguous length of colon. The
 small intestine is not involved, except in the setting of
 extensive colitis, in which the most distal terminal ileum
 may exhibit similar superficial inflammation, termed
 backwash ileitis. Because the extent of colitis usually
 remains constant from the onset, the length of involved
 colon defines the classification of UC: proctitis (limited to
 the rectum), proctosigmoiditis or left-sided colitis
 (extending up to the splenic flexure), or pancolitis
 (extending into the transverse colon).

 Download the video clips by clicking on the endoscopic
 images, if you wish to observe in full screen, wait to be
 downloaded complete then press Alt and Enter for
 Windows media, Real Player Ctrl and 3. 
 Configuration the windows media in repeat is optimal.
 All endoscopic images shown in this Atlas contain
 video clips. We recommend seeing the video clips in full
 screen mode.

Video Endoscopic Sequence 2 of 7.

A depressed ulcer is observed

 Proximal extension occurs in approximately one third of
 patients with distal disease, and regression from pancolitis
 is also possible The extent of involvement does not
 necessarily imply severity but does pertain to prognosis
 (e.g., the risk of cancer) and to treatment selection. The
 symptoms and course of UC relate to both the extent and
 the severity of inflammation within the involved segment of
 colon.

Video Endoscopic Sequence 3 of 7.

 Extensive colitis (pancolitis). In pancolitis, inflammation
 extends into the transverse or right colon. Patients are
 more likely to present with diarrhea because of diminished
 absorptive capacity of the colon, accompanied by rectal
 bleeding and urgency. Abdominal cramps may be diffuse or
 localized, and patients are more likely to have weight loss,
 systemic or extraintestinal symptoms, and anemia.

Video Endoscopic Sequence 4 of 7.

Endoscopy of Ulcerative Colitis

Clinical Severity

 The severity of UC depends on both the length of colon
 involved and the severity of colonic inflammation.

 In contrast to Crohn's disease, lower endoscopy in
 ulcerative colitis shows continuous and circumferential
 involvement, with no normal areas of mucosa.

Video Endoscopic Sequence 5 of 7.

The cecum, the Ileocecal valve

Clinical Severity

 Mild. In mild UC, patients have less than four bowel
 movements daily, with minimal cramps and urgency.
 Usually, most of the bowel movements occur early in the
 day; and after the morning evacuations, the patient is able
 to proceed with activities of daily life.

Video Endoscopic Sequence 6 of 7.

The cecum.

 Clinical Severity: Moderate. Patients with moderate UC have
 four to eight bowel movements daily, more frequent rectal
 urgency, and postprandial cramping and bowel movements.
 Blood is present in most stools, and nocturnal wakening for
 bowel movements is common. The disease can interfere with
 daily work or school activities and social life.

 Severe. Patients with severe UC have more than eight bowel
 movements daily, nocturnal bowel movements, severe urgency
 with or without incontinence, and systemic signs that include
 low -grade fever, night sweats, weakness, and weight loss.
 Abdominal tenderness, tachycardia, anemia, leukocytosis, and
 hypoalbuminemia are common.

 Fulminant. Patients with fulminant colitis have more than 10
 bowel movements a day, nocturnal bowel movements, severe
 abdominal pain or relentless tenesmus, and rebound tenderness
 or distention with tympanic bowel sounds. They also have
 prostration, high fever, and hypotension. Radiographic studies
 show evidence of mucosal edema, intramural air (pneumatosis
 coli), colonic dilatation (toxic megacolon), or free abdominal air
 (perforation).

Video Endoscopic Sequence 7 of 7.

Terminal Ileum

 This video clip shows the cecum, the endoscope is
 advancing into the ileocecal valve to the terminal ileum
 which is completely normal.

 Backwash Ileitis: Involvement of the distal ileum in
 ulcerative colitis (UC) is termed backwash ileitis (BWI). It
 generally is accepted as a distinct pathologic process in
 patients with UC.

Video Endoscopic Sequence 1 of 22.

Endoscopy of Ulcerative Colitis with Pseudopolyps

This 53 year-old female suffering of longstanding ulcerative colitis.

Pathophysiology

 Ulcerative colitis involves only the mucosa; it is
 characterized by the formation of crypt abscesses and a
 coexisting depletion of goblet cell mucin. In severe cases,
 the submucosa may be involved; in some cases, the deeper
 muscular layers of the colonic wall is also affected.

 Acute severe colitis may result in a fulminant colitis or toxic
 megacolon, which is characterized by a thin-walled, large,
 dilated colon that may eventually become perforated.
 Chronic disease is associated with pseudopolyp formation
 in about 15-20% of cases. Chronic and severe cases can be
 associated with areas of precancerous changes, such as
 carcinoma in situ or dysplasia.

 Anatomically, the large majority of cases involve the
 rectum; some patients develop terminal ileitis caused by an
 incompetent ileocecal valve. In these cases, about 30 cm of
 the terminal ileum is usually affected.

Video Endoscopic Sequence 2 of 22.

 Endoscopic findings in ulcerative colitis.  Endoscopy in UC
 typically reveals the following findings: Erythema Loss of
 the usual fine vascular pattern Granularity of the mucosa
 Friability Edema.

 The granular appearance is manifested by changes in light
 reflection during colonoscopy. Instead of reflecting light in
 large patches, the granular mucosa reflects a multitude of
 small points of light, giving the appearance of "wet
 sandpaper"

 In contrast to Crohn's disease, lower endoscopy in
 ulcerative colitis shows continuous and circumferential
 involvement, with no normal areas of mucosa.

Video Endoscopic Sequence 3 of 22.

Endoscopic View of Ulcerative Colitis with Pseudopolyps

Long segment of the transverse colon with Pseudopolyps

 They can range from a few millimeters in diameter to a
 centimeter or more. They tend to be taller than they are
 wide and can mimic neoplasms; biopsy confirms that they
 are not neoplastic . Pseudopolyps are associated with
 increased severity and more extensive involvement in UC.
 However, the outcome in patients with pseudopolyps is
 better than in those with similar disease extent and
 severity who do not have pseudopolyps.

Video Endoscopic Sequence 4 of 22.

 Endoscopy of Ulcerative Colitis with Pseudopolyps

 An important role for colonoscopy is in the surveillance of
 longstanding extensive ulcerative colitis where there is an
 increased risk of developing carcinoma.

 Show polyps made up primarily of granulation tissue.
 These when contiguous may fuse causing irregular masses.

.

Video Endoscopic Sequence 5 of 22.

 Endoscopic Image of Ulcerative Colitis with Pseudopolyps

 Inflammatory polyps (pseudopolyposis) Pseudopolyposis is
 a term hallowed by usage. It has, however, been suggested
 that there is nothing ‘pseudo’ about these polyps which
 should, more appropriately, be referred to as benign
 inflammatory polyps or regenerative polyps, depending on
 the histopathological appearances.

Video Endoscopic Sequence 6 of 22.

Gradual transition to normal mucosa.

 The extent of colitis usually remains constant from the
 onset with the length of colonic involvement defining the
 classification of ulcerative colitis: proctitis (limited to the
 rectum), proctosigmoiditis or left-sided colitis (extending up
 to the splenic flexure), or pancolitis/extensive colitis
 (extending into the transverse colon).

Video Endoscopic Sequence 7 of 22.

The appendicular area

 A subset of patients with UC demonstrates focal
 inflammation around the appendiceal orifice not contiguous
 with disease elsewhere in the colon.

Video Endoscopic Sequence 8 of 22.

A polyp in the ascending colon

Video Endoscopic Sequence 9 of 22.

Indications for Endoscopy in Ulcerative Colitis

 There are multiple indications for endoscopy in patients
 with ulcerative colitis, including initial diagnosis;
 differentiation from Crohn's disease, infectious, and other
 colitides; evaluation of extent of colonic involvement;
 determination of the activity and severity of disease;
 monitoring response to medical management; and
 surveillance for dysplasia and colorectal cancer.

Video Endoscopic Sequence 10 of 22.

The Hepatic Flexure

 Findings in UC begin at the anal verge and extend
 proximally. The involvement is contiguous and
 circumferential, with inflammation beginning from the point
 of origin and continuing to a gradual transition to normal
 mucosa.

Video Endoscopic Sequence 11 of 22.

 Endoscopic Appearance of Ulcerative Colitis with
 Pseudopolyps

 Biopsy or polypectomy of lesions greater than 1 cm in
 diameter or different in appearance or colour from their
 fellows is advisable to enable definition of polyp type and
 for exclusion of malignancy.

Video Endoscopic Sequence 12 of 22.

 Endoscopic Image of Ulcerative Colitis with Pseudopolyps

 Endoscopy of pseudopolyps; these lesions are not specific
 to ulcerative colitis, although they are more common in this
 disorder than in Crohn's disease.

Video Endoscopic Sequence 13 of 22.

 Random biopsies may reveal the changes of low grade or
 high grade dysplasia. The colonoscopist cannot usually
 distinguish flat dysplastic from normal mucosa, and the
 diagnosis therefore depends on the histopathological
 appearances. Dysplastic mucosa may however, be
 endoscopically visible as a DALM.

Video Endoscopic Sequence 14 of 22.

Frequency

United States

 In the Western world, ulcerative colitis has a prevalence of
 3-10 cases per 100,000 population. Ulcerative colitis is 3
 times more common than Crohn disease.

International

 Geographically, ulcerative colitis is more common in the
 Western and Northern hemispheres; the incidence is low in
 Asia and the Far East.

Video Endoscopic Sequence 15 of 22.

Endoscopic Image of Ulcerative Colitis with Pseudopolyps

 Some biopsies are taken

 Adenomatous polyps may occasionally be seen in patients
 with UC, though there is no etiological relationship.

.

Video Endoscopic Sequence 16 of 22.

 Ulcerative colitis may result in disease-related mortality.
 However, overall mortality is not increased in patients with
 ulcerative colitis, as compared with the general population.
 An increase in mortality may be observed among
 elderly patients with the disease. Mortality is also
 increased in patients who develop complications (eg, shock,
 malnutrition, anemia). Evidence suggests that mortality is
 increased in patients with ulcerative colitis who undergo
 any form of medical or surgical intervention.

Video Endoscopic Sequence 17 of 22.

Race

Ulcerative colitis is more common in individuals living in
 temperate climates and in whites. There are sporadic
 increases in some Jewish populations. The disease is
 uncommon in the Far East.

Sex

 Ulcerative colitis is slightly more common in men than in
 women.

Video Endoscopic Sequence 18 of 22.

Age

 Ulcerative colitis is uncommon in persons younger than 10
 years. Most patients are 20-40 years of age at diagnosis.
 Another peak occurs at 60 years of age.

Video Endoscopic Sequence 19 of 22.

Video Endoscopic Sequence 20 of 22.

Video Endoscopic Sequence 21 of 22.

Video Endoscopic Sequence 22 of 22.

Video Endoscopic Sequence 1 of 4.

Ulcerative colitis complicating pseudomembranous colitis of the right colon.

 A 73-year-old man presented with chronic watery diarrhea
 and abdominal cramping of three months duration. Was
 under multiple antibiotics therapy prescribed from his
 general practitioner.

Video Endoscopic Sequence 2 of 4.

 This image and the video clip display a long tract of the
 descending colon with ulcerative colitis.

Video Endoscopic Sequence 3 of 4.

 Ulcerative Colitis and superimposed pseudomembranous
 colitis involving the right colon.

 Colonoscopy revealed pseudomembranous colitis extending
 from the ascending colon to the cecum, and Clostridium
 Difficile, toxin was positive in the feces. The administration
 of vancomycin in addition to oral steroids resulted in rapid
 improvement of the condition.

Video Endoscopic Sequence 4 of 4.

 Endoscopic Image of Ulcerative Colitis with superimposed
 pseudomembranous colitis.

 Total colonoscopy is recommended for precise diagnosis
 when patients with ulcerative colitis develop intractable
 diarrhea during or after antibiotic therapy.

Video Endoscopic Sequence 1 of 4.

Ulcerative colitis complicating Colon Cancer

 Longstanding extensive UC is associated with a
 significantly increased risk of developing colon cancer.
 Colonoscopic surveillance is increasingly used in this group
 of patients.

• Patients with ulcerative colitis have a 2 to 8 fold increased risk of developing colorectal cancer compared to the general population.
   
•  Colorectal cancer influences long term survival in patients with ulcerative colitis.
   
•  Stage of colorectal cancer at time of diagnosis is an important predictor of survival.

Video Endoscopic Sequence 2 of 4.

This image shows a colonic cancer of the rectosigmoid junction.

Patients with ulcerative colitis and colorectal cancer have a stage distribution similar to patients with colorectal cancer without ulcerative colitis.

Survival of colorectal cancer is poorer for patients with ulcerative colitis than for patients with colorectal cancer without ulcerative colitis.
 

Video Endoscopic Sequence 3 of 4.

 Longstanding extensive UC is associated with a
 significantly increased risk of developing colon cancer.
 Colonoscopic surveillance is increasingly used in this group
 of patients.

 It is well documented that there is an increased risk of
 developing cancer in ulcerative colitis when compared to
 the general population, although it is now thought that the
 risk is much lower than previously believed.

Video Endoscopic Sequence 4 of 4.

 In a patient with long-standing ulcerative colitis undergoing
 surveillance colonoscopy, the primary question is whether
 or not there is dysplasia present and not to make a
 diagnosis of inflammatory bowel disease.

Video Endoscopic Sequence 1 of 5.

Endoscopy of Ulcerative Colitis.

 Endoscopic findings in ulcerative colitis — Endoscopy in
 UC typically reveals the following findings:
 Erythema
 Loss of the usual fine vascular pattern
 Granularity of the mucosa
 Friability
 Edema.

Video Endoscopic Sequence 2 of 5.

 This image and the video clips shows the typical
 serpinginous ulcers of ulcerative colitis after using indigo
 carmine stain.

 Chromoendoscopy is characterized by intravital staining of
 colonic epithelium to enhance dysplastic mucosal changes,
 thereby allowing targeted biopsies of suspicious lesions.
 Indigo carmine is a contrast dye that has the ability to coat
 the colonic mucosa and allow identification of the disruption
 of normal surface mucosal grooves. In comparison,
 methylene blue is an absorptive dye, which avidly stains
 normal mucosa, but is poorly absorbed by inflamed or
 dysplastic mucosa. The combination of chromoendoscopy
 and use of magnifying colonoscopes facilitates a thorough
 evaluation of mucosal details, which may not be discerned
 on routine colonoscopy.

Video Endoscopic Sequence 3 of 5.

 High magnification of the ulcers.

 In order to detect flat-type dysplastic and cancerous lesions
 associated with longstanding ulcerative colitis, it is
 important to understand the minute findings detected by
 magnifying colonoscopy in active and quiescent stage of
 ulcerative colitis. The severity of mucosal findings by
 magnifying colonoscopy could be categorized as follows:
 polypoid mucosal tag which has severe ulceration and
 hemorrhage; coral-reef-like appearance which has coarse
 or nodular mucosa with ulcerations; minute defect of
 epithelia which has minute or shallow depressions
 surrounded by edematous mucosa; small yellowish spots
 which has minute whitish or yellowish coats; villi-like
 appearance which has shaggy appearance like small
 intestinal villi; and regularly arranged crypt opening which
 has round shaped and regularly arranged crypt.

Video Endoscopic Sequence 4 of 5.

 A focal area of ulcerative colitis is appreciated, showing
 redness and ulcerations.

 A pit-pattern classification has been developed based upon
 the staining pattern, which allows endoscopic prediction of
 histopathologic findings with an accuracy of 93%: Type I
 and II staining patterns are consistent with nonneoplastic
 lesions, and types III through V predict neoplastic lesions.
 Chromoendoscopy can increase the yield of neoplastic
 lesions detected in ulcerative colitis by 3- to 4.5-fold as
 compared with conventional colonoscopy.

Video Endoscopic Sequence 5 of 5.
 

 A high magnification of a focal area of ulcerative colitis.

Video Endoscopic Sequence 1 of 3.

Endoscopy of Ulcerative Colitis.

 There are several serpingenous ulcer´s. friability,
 exudation, and bleeding, with increasingly larger areas of
 ulcerations.

Video Endoscopic Sequence 2 of 3.

 More images of ulcerative colitis, with increasingly larger
 areas of ulcerations.
 

Video Endoscopic Sequence 3 of 3.

 Chromoendoscopy using methilene blue.

                                                                            
 
                                                                                 Medline:
 In  some clinical trials, it has been using Methylene blue-aided
 chromoendoscopy for the detection of intraepithelial neoplasia
 and colon cancer in ulcerative colitis.

Video Endoscopic Sequence 1 of 6.

Case of  severe ulcerative colitis.

 The muco

There are cryptic microabsceses, chronic inflamation of  colonic mucosa and loss of glands, Click on the  histopathological  image to enlarge it.

sa is friable, erythematous, and edematous.        

Video Endoscopic Sequence 2 of 6.

Ulcerative Colitis.

 The recto-sigmoid junction.
 Coarsely nodular deformity of mucosal contour in
 ulcerative colitis. The mucosa is erythematous and friable.
 Coarsely nodular deformity of mucosal contour in
 ulcerative colitis.

Video Endoscopic Sequence 3 of 6.

 Ulcerative Colitis.

 Moderate to severe colitis is characterized by granularity,
 friability, exudate, spontaneous bleeding  and  increasingly
 larger areas of ulceration.
 Pathophysiology: Ulcerative colitis is defined as continuous
 idiopathic inflammation of the colonic or rectal mucosa.
 The rectum is involved in more than 95% of cases. Some
 authorities believe that the rectum is always involved in an
 untreated patient. Partial healing may occur in a patient
 treated with topical therapy, creating diagnostic confusion.

Video Endoscopic Sequence 4 of 6.

Ulcerative Colitis.

 Necrosis, edema, exudate and friability are observed.
 Causes:
 An unknown factor causes an immune-mediated
 inflammatory response in the intestinal mucosa.
 Genetic susceptibility (chromosomes 12 and 16) is a factor
 associated with ulcerative colitis.
 A positive family history (observed in 1 of 6 relatives) is        associated with a higher risk for developing the disease.
 Smoking is not associated with ulcerative colitis                      This relationship is reversed in Crohn disease.            
                          Environmental factors.
 Dietary factors: Milk consumption may exacerbate the
 disease.
 Appendectomies have a negative association with
 ulcerative colitis.

 

Video Endoscopic Sequence 5 of 6.

Ulcerative Colitis.

 Some biopsies are taken from irregular areas in order to
 rule out malignancy or dysplasia.

There are ulcer and purulent exudate of colonic   mucosa. Click on the histopathological image to   enlarge it.

Video Endoscopic Sequence 6 of 6.

Ulcerative Colitis.

 Multiples pseudopolyposis are seen and the video clip
 displays hundreds of pseudopolyps.

There are pseudopolyps chronic inflamation  of colonic mucosa, click on the histopathological image  to enlarge it.

Video Endoscopic Sequence 1 of 3.

Ulcerative Colitis of long stand evolution.

 On the image and the video clip are observed multiple
 pseudo polyps and scar areas of the ascending colon.
 There are pseudopolyps and chronic inflammation
 of colonic mucosa.

Video Endoscopic Sequence 2 of 3.

 The video clip displays the cecum; a pseudo polyp is
 observed; some biopsies were taken.

Video Endoscopic Sequence 3 of 3.

 The biopsy forceps is observed.

 

Ulcerative Colitis.

 There are several serpingenous ulcers with pseudo polyps,
 friability, exudate, and bleeding, with increasingly larger
 areas of ulcerations.
  

Video Endoscopic Sequence 1 of 2.

 A 65 year-old male presented with chronic diarrhea Rectal
 bleeding associated with the passage of mucus

 The image and the video clip displays a pancolitis.
 The mucosa is friable, erythematous, and edematous.
 This is uniform throughout the entire circumference of the
 colon.
   

Video Endoscopic Sequence 2 of 2.

Ulcerative Colitis.

Collagenous Colitis.

 A 37 year-old female with diarrhea of 6 months. She was
 hospitalized in another institution, a barium enema
 performed and The Rx resulted negative; the entire colon
 was affected with segmental redness. Patients are usually
 middle-aged women (9:1 is the female-male ratio in
 collagenous colitis).