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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.
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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.
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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.
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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.
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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.
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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).
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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.
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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.
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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.
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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.
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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.
Psychological and psychosocial stress factors can play a
role in the presentation of ulcerative colitis and can
precipitate exacerbations.
Smoking is negatively associated with ulcerative colitis.
This relationship is reversed in Crohn disease.
Milk consumption may exacerbate the disease..
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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.
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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).
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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.
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Video Endoscopic Sequence 8 of 22.
A polyp in the ascending colon
The severity of ulcerative colitis can be graded as follows:
Mild - Bleeding per rectum and fewer than 4 bowel motions per day
Moderate - Bleeding per rectum with more than 4 bowel motions per day
Severe - Bleeding per rectum, more than 4 bowel motions per day, and a systemic illness with hypoalbuminemia (< 30 g/L).
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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Video Endoscopic Sequence 19 of 22.
The diagnosis of ulcerative colitis is best made with
endoscopy. Endoscopically, ulcerative colitis is
characterized by abnormal erythematous mucosa, with or
without ulceration, extending from the rectum to part or all
of the colon. The inflammation is uniform, without
intervening areas of normal mucosa, while skip lesions
tend to characterize Crohn disease. Contact bleeding may
also be observed, with mucus identified in the lumen of the
bowel. Biopsy of the mucosa is recommended to identify
the extent of the disease with respect to the thickness of
the bowel wall.
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Video Endoscopic Sequence 20 of 22.
Histologically, most of the pathology is limited to the
mucosa and submucosa. In fulminant cases, the muscularis
propria can be affected. Pathologic features that are
typically seen include intense infiltration of the mucosa and
submucosa with neutrophils and crypt abscesses, lamina
propria with lymphoid aggregates, plasma cells, mast cells
and eosinophils, and shortening and branching of the crypts.
These features are not unique to ulcerative colitis. Except
for crypt distortion, the same cellular response can be seen
in acute infectious colitis or Crohn disease.
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Video Endoscopic Sequence 21 of 22.
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Video Endoscopic Sequence 22 of 22.
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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.
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Video Endoscopic Sequence 2 of 4.
This image and the video clip display a long tract of the
descending colon with ulcerative colitis.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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Video Endoscopic Sequence 5 of 5.
A high magnification of a focal area of ulcerative colitis.
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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.
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Video Endoscopic Sequence 2 of 3.
More images of ulcerative colitis, with increasingly larger
areas of ulcerations.
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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.
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Video Endoscopic Sequence 1 of 6.
Case of severe ulcerative colitis.
The muco
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There are cryptic microabsceses, chronic inflamation of
colonic mucosa and loss of glands, Click on the
histopathological image to enlarge it.
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sa is friable, erythematous, and edematous. |
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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.
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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.
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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.
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Video Endoscopic Sequence 5 of 6.
Ulcerative Colitis.
Some biopsies are taken from irregular areas in order to
rule out malignancy or dysplasia.
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There are ulcer and purulent exudate of colonic
mucosa. Click on the histopathological image to
enlarge it.
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Video Endoscopic Sequence 6 of 6.
Ulcerative Colitis.
Multiples pseudopolyposis are seen and the video clip
displays hundreds of pseudopolyps.
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There are pseudopolyps chronic inflamation
of colonic mucosa, click on the histopathological image
to enlarge it.
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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.
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Video Endoscopic Sequence 2 of 3.
The video clip displays the cecum; a pseudo polyp is
observed; some biopsies were taken.
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Video Endoscopic Sequence 3 of 3.
The biopsy forceps is observed.
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Ulcerative Colitis.
There are several serpingenous ulcers with pseudo polyps,
friability, exudate, and bleeding, with increasingly larger
areas of ulcerations.
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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.
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Video Endoscopic Sequence 2 of 2.
Ulcerative Colitis.
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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).
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Video Endoscopic Sequence 1 of 25.
Case of Severe Ulcerative Colitis
The image and the video clips shows an atypical perianal fissure
This is a 52 year old male spanish, with longstanding
ulcerative colitis. Four months previously he came to our
endoscopic unit for the management of this disease. The
first time he had a frequency of 10 to 20 mucosanguineous
evacuations per day and severe edema of the legs with a
20 lbs weight loss. His general aspect was of a critacally ill
patient.
Initially, he had had an excellent improvement of his
clinical picture with the therapy with Infliximab. The patient
regained over 20 pounds of his weight, but it was only
during this period, because then he relapsed dramatically
with exacerbation.of this disease.
Despite of the treatment, again with weight loss of 20 lbs.
The patient reappears the severe edema of the legs with
tachycardia and elevation of the white blood cell count with
22.000 with 92% of neutrophils.
Due to sudden deterioration underwent surgery
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Video Endoscopic Sequence 2 of 25.
Findings on the comprehensive metabolic panel may include the following:
Hypoalbuminemia (ie, albumin < 3.5 g/dL)
Hypokalemia (ie, potassium < 3.5 mEq/L)
Hypomagnesemia (ie, magnesium < 1.5 mg/dL)
Elevated alkaline phosphatase: More than 125 U/L
suggests primary sclerosing cholangitis (usually >3 times
the upper limit of the reference range).
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Video Endoscopic Sequence 3 of 25.
Grossly, the colonic mucosa appears hyperemic, with loss
of the normal vascular pattern. The mucosa is granular
and friable. Frequently, broad-based ulcerations cause
islands of normal mucosa to appear polypoid, leading to the
term pseudopolyp.
Ulcerative colitis is a chronic disease associated with
diffuse mucosal inflammation of the colon, giving rise to
significant morbidity and recurrent symptoms of
intermittent bloody diarrhea, rectal urgency, and tenesmus.
Onset of symptoms typically occurs between 15 and 40
years of age, with a second peak in incidence between 50
and 80 years of age. Men and women are equally likely to
develop ulcerative colitis.
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Video Endoscopic Sequence 4 of 25.
Pseudopolyps are observed
The bowel wall is thin or of normal thickness, but edema,
the accumulation of fat, and hypertrophy of the muscle
layer may give the impression of a thickened bowel wall.
The disease is largely confined to the mucosa and, to a
lesser extent, the submucosa. Muscle-layer and serosal
involvement is very rare; such involvement is seen in
patients with severe disease, particularly toxic dilatation,
and reflects a secondary effect of the severe disease
rather than primary ulcerative colitis pathogenesis.
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Video Endoscopic Sequence 5 of 25.
Endoscopic image of Ulcerative Colitis with multiple ulcers and pseudopolyps.
Early disease manifests as hemorrhagic inflammation with
loss of the normal vascular pattern; petechial
hemorrhages; and bleeding. Edema is present, and large
areas become denuded of mucosa. Undermining of the
mucosa leads to the formation of crypt abscesses, which
are the hallmark of the disease.
The diagnosis of ulcerative colitis is best made with
endoscopy and mucosal biopsy for histopathology.
Laboratory studies are helpful to exclude other diagnoses
and assess the patient's nutritional status, but serologic
markers can assist in the diagnosis of inflammatory bowel
disease.
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Video Endoscopic Sequence 6 of 25.
Ulcerative colitis is a lifelong illness that has a profound emotional and social impact on affected patients.
Treatment of Acute, Severe Disease
Acute, severe ulcerative colitis (ie, >6 bloody bowel
movements/d, with one of the following: fever >38°C,
hemoglobin level < 10.5 g/dL, heart rate >90 bpm,
erythrocyte sedimentation rate >30 mm/h, or C-reactive
protein level >30) requires hospitalization and treatment
with intravenous high-dose corticosteroids (hydrocortisone
400 mg/d or methylprednisolone 60 mg/d). A meta-analysis
supports the use of glucocorticosteroids in inducing
remission in acute severe ulcerative colitis.
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Video Endoscopic Sequence 7 of 25.
Involvement of the muscularis propria in the most severe
cases can lead to damage to the nerve plexus, resulting in
colonic dysmotility, dilation, and eventual infarction and
gangrene, a condition termed toxic megacolon. This
condition 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.
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Video Endoscopic Sequence 8 of 25.
Chronic ulcerative colitis is associated with an increase in
the risk of carcinoma, and a colonic carcinoma may easily
be missed in the setting of ulcerative colitis. Patients with
ulcerative colitis must be made aware of the significant
risk of colon cancer, and surgical intervention in nonacute
cases should be encouraged after 10 years of disease or
when symptoms are refractory or steroid dependent.
Indications for surgery in ulcerative colitis vary and are
discussed in detail in Surgical Treatment.
As yet, no evidence suggests that regular endoscopic
screening of patients with ulcerative colitis improves
survival. However, the current standard of practice by
many gastroenterologists is to continue screening these patients at some interval, owing to the risk of cancer
development and possible legal implications if it is not detected.
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Video Endoscopic Sequence 9 of 25.
Patients with severe disease can have signs of volume depletion and toxicity, including the following:
Fever
Tachycardia
Significant abdominal tenderness
Weight loss
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Video Endoscopic Sequence 10 of 25.
The most common cause of death of patients with
ulcerative colitis is toxic megacolon. Colonic
adenocarcinoma develops in 3-5% of patients with
ulcerative colitis, and the risk increases as the duration of
disease increases. The risk of colonic malignancy is higher
in cases of pancolitis and in cases in which onset of the
disease occurs before the age of 15 years. Benign stricture
rarely causes intestinal obstruction.
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Video Endoscopic Sequence 11 of 25.
The surgical specimen is observed
Historically, surgery has been viewed as definitive therapy
for ulcerative colitis. Total proctocolectomy is often
curative, alleviating symptoms and removing the risk of
colonic adenocarcinoma. Prior to 1980, total
proctocolectomy with end ileostomy or continent (or Koch)
ileostomy was the mainstay of therapy.
To enlarge the image press on it
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Video Endoscopic Sequence 12 of 25.
Historically, surgery has been viewed as definitive therapy
for ulcerative colitis. Total proctocolectomy is often
curative, alleviating symptoms and removing the risk of
colonic adenocarcinoma. Prior to 1980, total
proctocolectomy with end ileostomy or continent (or Koch)
ileostomy was the mainstay of therapy.
Indications for urgent surgery in patients with ulcerative colitis include the following:
Toxic megacolon refractory to medical management
Fulminant attack refractory to medical management
Uncontrolled colonic bleeding
Perforation (free or walled off)
Obstruction and stricture with suspicion for cancer.
Indications for elective surgery in ulcerative colitis include the following:
Refractory disease with failure of medical management
Chronic steroid dependency
Dysplasia or adenocarcinoma found on screening biopsy
Disease present 7-10 years
Systemic complications from medications, particularly
steroids
Failure to thrive, in children.
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Video Endoscopic Sequence 13 of 25.
Abdomen MRI of our patient
Advances in MR technology have improved the quality of
abdominal MRI and hence the ability to assess intestinal
diseases. Rapid acquisition sequences have reduced the
incidence of motion artifacts from intestinal peristalsis,
while the use of phased-array coils has increased spatial
resolution. Several intestinal contrast agents have
undergone extensive trials. Meanwhile, the use of
sequences that modulate MRI signal selectively, for
example by suppressing fat tissue signal, can improve
gadolinium-related enhancement on T1-weighted images,
as well as boosting T2 signal in pathologic tissues.
These improvements-together with the intrinsic capability
of multiplanar acquisition, the use of different imaging
parameters, inherently high soft-tissue contrast, and the
lack of ionizing radiation-make MRI a useful, effective
tool for evaluating the normal bowel and detecting
intestinal wall changes indicative of neoplastic and
inflammatory bowel diseases.
To enlarge the image press on it
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Video Endoscopic Sequence 14 of 25.
Colonic wall thickening is usually less extensive in
ulcerative colitis than in Crohn's disease. CT studies have
shown the mean value of wall thickening to be 7 mm vs. 13
mm, respectively.10-14 The thickening can be visualized
easily on either T1- or T2-weighted MR sequences,
preferably on axial images.
Marked thickening of the rectal or colonic wall exceeding
10 mm can be observed in ulcerative colitis as well in
severe phases of activity. The wall's inner profile can show
a waved configuration in both ulcerative colitis and Crohn's
disease. The outer wall profile is sharper and smoother in
ulcerative colitis, due to the intramural rather than
transmural extent of inflammation.
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Video Endoscopic Sequence 15 of 25.
Cross-sectional imaging studies such as CT, MRI, and US
are useful for showing the effects of these conditions on the
wall of the bowel and for demonstrating intra-abdominal
abscesses and other extraluminal findings in patients with
more advanced disease. Thus, barium studies and
cross-sectional imaging studies have complementary roles
in the evaluation of ulcerative colitis.
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Video Endoscopic Sequence 16 of 25.
There is a foot abscess that appear with the exacerbation.
Extracolonic manifestations
Ulcerative colitis is associated with various extracolonic
manifestations. These include uveitis, pyoderma
gangrenosum, pleuritis, erythema nodosum, ankylosing
spondylitis, and spondyloarthropathies. Reportedly, 6.2%
of patients with inflammatory bowel disease have a major
extraintestinal manifestation. Uveitis is the most common,
with an incidence of 3.8%, followed by primary sclerosing
cholangitis at 3%, ankylosing spondylitis at 2.7%,
erythema nodosum at 1.9%, and pyoderma gangrenosum
at 1.2%.However, reports vary, and some have stated that
the incidence of ankylosing spondylitis is as high as 10%.
Arthropathies occur in as many as 39% of patients with
inflammatory bowel disease. About 30% of such patients
have inflammatory back pain, 10% have synovitis, and as
many as 40% have radiologic findings of sacroiliitis.
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Video Endoscopic Sequence 17 of 25.
Another image of the foot abscess
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Video Endoscopic Sequence 18 of 25.
An subcutaneous abscess near to the clavicular notch that appear with the exacerbation of the disease.
The association of pyoderma gangrenosum or erythema
nodosum with UC is well known. In addition, pustular
eruption has been reported in UC. Our patient with UC who
exhibited subcutaneous abscesses, as well as pustular
eruption with a clinical course paralleling that of UC
exacerbation.
Anecdotal reports of recurrent subcutaneous abscesses
unrelated to pyoderma gangrenosum exist, and multiple
sclerosis also has been weakly associated with ulcerative
colitis.
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Video Endoscopic Sequence 19 of 25.
The subcutaneous abscess was drainage
Extraintestinal complications affect 25-30% of patients
with ulcerative colitis. These extraintestinal disorders
significantly contribute to morbidity and mortality of
ulcerative colitis patients. While some disorders parallel
the activity of the colitis, other abnormalities run a clinical
course independent of the bowel disease. The pathogenesis
of these disorders is unknown, but the variable
relationships to the severity of colitis and the variable
responses to a proctocolectomy suggest considerable
heterogeneity.
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Video Endoscopic Sequence 20 of 25.
The subcutaneous abscess was drainage on his foot
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Video Endoscopic Sequence 21 of 25.
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Video Endoscopic Sequence 22 of 25.
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Video Endoscopic Sequence 23 of 25.
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Video Endoscopic Sequence 24 of 25.
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Video Endoscopic Sequence 25 of 25.
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