Video Endoscopic Sequence 1 of 110.

 This is the case of 50 year-old female, three years previous
 was diagnosed as having ulcerative colitis in another
 country. The clinical course began with severe constipation
 during 6 month following with bloody loose bowel
 movements.

 Now presented with frequent episodes of rectal bleeding
 with mucus, diarrhea, rectal pain, urgency, tenesmus,
 intermitent severe abdominal pain referred to left flank,
 and pitting edema of the both leg, Hb 10.8 gr/dl.
 hypoalbuminemia, elevated platelet count, extreme fatigue,
 patient looks pale and weight loss of 30 libs.

 CT scan shows ingorged splenic angle and
 descending colon with ascites. Pacient is admitted for
 stabilization.

 Because of the severity of the clinical picture and the
 severity and extention of the pancolitis, surgery was
 initially suggested as a treatment option, but patient
 instead chose medical management, which included
 prednisone 50 mg PO daily for 10 days, gradually
 diminishing doses by 10 mg/day every 10 days, plus
 sulfidine 2 tablets PO after every meal. Corticosteroids
 should be used to treat active ulcerative colitis. They have
 no role in maintenance treatment to prevent relapse. The
 dosage and routes of administration vary with the severity
 and location of ulcerative colitis.

 After 10 days of treatment and 18 after the colonoscopy,
 the patient is readmitted to the hospital because of
 increased abdominal pain and sepsis. WB counts: 21,900
 with 98% neutrophils, with a hemoglobin of 10 g/dl. Next
 day, patient presents with hypotension, tachycardia and
 signs of tissue hypoperfusion those sign are consistent of
 toxic megacolon .

 The patient underwent emergency surgery
 (Colectomy with ileostomy).

 All endoscopic images of this atlas download a video clip

Video Endoscopic Sequence 2 of 110.

 A full colonoscopy was performed. There are multiple
 rectal ulcers. 

 The are multiple deep ulcers and loss of normal vascular
 pattern in the rectal area that have to disclose Crohn
 disease or Cytomegalovirus Colitis.

Video Endoscopic Sequence 3 of 110.

The image and the video clips show a deep rectal ulcer.

 Endoscopic images show multiple ulcerations in the rectal
 area, with the first ulcer immediate to the pectinate line,
 with a more severe pattern of ulceration above the
 rectosigmoid juction.

Video Endoscopic Sequence 4 of 110.

The recto-sigmoid juction

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

Video Endoscopic Sequence 5 of 110.

Close up of deep and large ulcer in the rectum

 Severe ulcerative colitis, the least common form of the
 disease, occurs in 15% of all patients with ulcerative colitis.
 This form of the disease may be the initial presentation or
 may represent a progression from a less severe attack.
 Diarrhea is profuse and rectal bleeding is constant and
 severe. Fever is marked and sustained, and appetite and
 weight are both severely diminished. Abdominal cramps
 are severe and tenderness may be localized, indicating
 impending perforation. Leukocytes greater than 10,000,
 severe anemia, and hypoalbuminemia resulting from low
 protein intake (anorexia) and increased chronic loss of
 albumin are hallmarks of this form of the disease.

 Medical therapy is often ineffective for this type of patient
, and colectomy is often required.

Video Endoscopic Sequence 6 of 110.

Multiple biopsies across the colon was acquired.

Hospitalization

 Hospitalization is indicated for the following reasons:
 1. Failure of mild disease to improve significantly within
 four weeks of the start of outpatient treatment.
 Hospitalization removes the patient from an aggravating
 environment and provides the physician with the
 opportunity to initiate more effective and intensive
 therapeutic measures.
 2. Severe illness with anorexia, nausea, vomiting, fever and
 uncontrollable bloody diarrhea (severe ulcerative colitis).
 Early hospitalization is critical for such patients so that
 they may be provided with therapy to control the disease
 and prevent complications, especially toxic megacolon.
 3. Development of local or systemic complications
 including massive hemorrhage, persistent anemia, severe
 hypoalbuminemia, and/or cancer. Hospitalization at this
 time provides for assessment of the need for surgical
 therapy.

Video Endoscopic Sequence 7 of 110.

 Mesalamine (5-aminosalicylic acid mesalazine, or
 5-ASA) has been shown to be the active part of
 sulfasalazine and is effective in the treatment of active
 disease and in maintenance therapy to prevent relapse.

Video Endoscopic Sequence 8 of 110.

 Mucosal biopsies are useful both for confirming the
 diagnosis and for accurately defining the extent of
 ulcerative colitis, which can be underestimated on the basis
 of endoscopic appearance alone. In addition to its role in
 the initial evaluation of IBD, endoscopy is an effective
 tool in the reevaluation of patients with indeterminate
 colitis. According to a prospective population-based study,
 33% of patients with indeterminate colitis could be
 reclassified as ulcerative colitis after 1-2 years of follow-up.
 

Video Endoscopic Sequence 9 of 110.

 Splecnic Angle

 Colonoscopy with ileoscopy is the preferred endoscopic
 procedure in the initial evaluation of patients with
 suspected inflammatory bowel disease (IBD).
 Colonoscopy allows for direct mucosal visualization and
 biopsies, thereby facilitating the diagnosis and
 determination of colonic extent, activity, and severity of
 ulcerative colitis.

Video Endoscopic Sequence 10 of 110.

 Endoscopy of Severe Ulcerative Colitis

 Severe colitis noted during colonoscopy. The mucosa is
 grossly denuded and multiple pseudopolyps.

 Extensive colitis (pancolitis) is diagnosed when
 inflammation extends into the transverse or right colon.
 In this setting patients are more likely to present with
 diarrhea as a result of the diminished absorptive capacity
 of the colon, accompanied by rectal bleeding, urgency and
 tenesmus. Cramping abdominal pain may be diffuse or
 localized, and patients are more likely to have weight loss,
 systemic or extraintestinal symptoms, and anemia.

Video Endoscopic Sequence 11 of 110.

 The image shows confluent superficial ulceration, and loss
 of mucosal architecture.

 The clinical severity of ulcerative colitis depends on both
 the length of colon involved and the severity of colonic
 inflammation.

 Severe ulcerative colitis is manifest by more than eight
 bowel movements daily, nocturnal bowel movements,
 severe urgency with or without incontinence, and systemic
 signs including low-grade fever, night sweats, weakness,
 and weight loss. Abdominal tenderness, tachycardia,
 anemia, leukocytosis, and hypoalbuminemia are common.

Video Endoscopic Sequence 12 of 110.

Colonoscopy of Severe Ulcerative Colitis

 Advanced and severe active disease. When ulcerative colitis
 is moreadvanced and severe, the inflamed mucosa is often
 covered with purulent exudate.

Video Endoscopic Sequence 13 of 110.

Extensive Pseudopolyposis

 There may be considerable overlap between the
 endoscopic findings in ulcerative colitis and other colitides
 such as infectious, ischemic, and radiation colitis.
 Endoscopic features common to these disorders include
 erythema, edema, and granularity of the colonic mucosa.
 The use of nonsteroidal anti-inflammatory drugs
 (NSAIDs), sodium phosphate-based bowel preparations,
 hydrogen peroxide, and glutaraldehyde solutions used for
 scope disinfection can induce colonic mucosal changes,
 resembling IBD.

Video Endoscopic Sequence 14 of 110.

 Twenty to 25% of patients with extensive ulcerative colitis
 eventually undergo colectomy, usually because their
 disease has not responded to medical therapy.
 The decision between surgery and continued medical
 therapy is often not clear-cut, and in many cases
 arguments can be made for either course. In ulcerative
 colitis, colectomy is a “curative” procedure, in contrast to
 Crohn’s disease, in which there is a significant likelihood
 of recurrence some time after the colectomy. The
 development of the ileoanal anastomosis, eliminating the
 need for an ileostomy, has made the thought of colectomy
 more tolerable for many. In general, patients who require
 continuous high-dose cortico-steroids and/or
 immunosuppressants to keep their disease under control
 should be strongly advised to consider colectomy.
 Those at high risk for colonic carcinoma (pancolitis of
 greater than 10 to 15 years duration) should also be
 considering colectomy or alternatively entry into a
 colonoscopic surveillance program.

Video Endoscopic Sequence 15 of 110.

 Patients with ulcerative colitis are susceptible to
 superimposed bacterial or viral colitis, and furthermore,
 one third of patients with suspected IBD may in fact have
 an underlying infectious etiology for their colitis. Rectal
 biopsies showing histopathologic findings of a chronic
 inflammatory infiltrate, basal lymphoid aggregates, and
 architectural distortion may be useful in differentiating
 IBD from self-limited colitis with a probability of up to 80%

Video Endoscopic Sequence 16 of 110.

The mucosa of the ascending colon appers normal

 Complete colonoscopy into the cecum and terminal ileum
 is most helpful in distinguishing ulcerative colitis from
 Crohn’s disease.

 Ulcerative colitis is characterized by diffuse, superficial
 inflammation of the colonic mucosa that begins in the
 rectum and extends proximally to involve any contiguous
 length of colon. The small bowel is not involved, although
 the distal ileum may exhibit similar superficial
 inflammation, usually in the setting of extensive colitis,
 termed backwash ileitis.

Video Endoscopic Sequence 17 of 110.

The Cecum

 Is it important to observe this colonoscopy taken 18 days
 before the surgery, in that date in the coloscopy the cecum
 and ascending colon appeared of normal appearance,
 nevertheless the inflammatory activity of this disease has
 been quite severe and progressive in spite of medical
 treatment. See the video clips of the surgical specimen.

Video Endoscopic Sequence 18 of 110.

Hepatic angle: gradual transition to normal mucosa.

 At the time of the colonoscopy the inflamatory activity was
 to the transverse colon almost limiting to the hepatic angle,
 nevertheless the inflamatory activity was progresive that
 18 days after, the surgical specimen shows multiple ulcers
 and pseudopolyposis in the ascending colon and cecum.

Video Endoscopic Sequence 19 of 110.

 Endoscopic View of Severe Ulcerative Colitis

 Inflammatory pseudopolyps may be seen in patients with
 severe ulcerative colitis, and occur due to inflamed and
 regenerating mucosa surrounded by ulcerations, resulting
 in a cobblestone appearance at endoscopy. Pseudopolyps
 do not regress with treatment and tend to persist even in
 the presence of quiescent disease. They cannot be
 distinguished from neoplastic polyps on the basis of
 endoscopic appearance alone, and therefore
 histopathologic examination of polyps that display atypical
 features may be necessary to exclude dysplasia and/or
 malignancy.

Video Endoscopic Sequence 20 of 110.

 Endoscopic Image of Severe Ulcerative Colitis

 Acute severe ulcerative colitis is a medical emergency.
 Recognition of severe ulcerative colitis is based on a
 comprehensive clinical assessment. The Truelove and
 Witts criteria still remain useful in characterizing the
 severity of this condition.

Video Endoscopic Sequence 21 of 110.

 Colonoscopy of Severe Ulcerative Colitis

 Pseudopolyposis is a frequent sequela of ulcerative colitis
 (UC), pseudopolyposis may grow to a very large size,
 producing a mass-like appearance called localized giant
 pseudopolyposis or inflammatory polyposis of the colon.
 This rare lesion mimics villous adenoma or carcinoma on
 barium enema and conventional endoscopy.

Video Endoscopic Sequence 22 of 110.

Extensive Ulceration with Pseudopolyposis

Video Endoscopic Sequence 23 of 110.

 Pseudopolyps are knobby, bulging areas of mucosa
 resulting from necrosis. They occur as multiple polyps and
 can be several centimeters long. They often have a soft,
 whitish surface, though sometimes they can be tinged with
 blood. Pseudopolyps can also occur as bridging folds.

Video Endoscopic Sequence 24 of 110.

 Endoscopic Appearance of Severe Ulcerative Colitis

 Localized giant pseudopolyposis is seen in both UC and
 Crohn’s disease. Pseudopolyps are formed by ulceration,
 which undermines the muscularis mucosae and creates
 mucosal tags that remain as polyps after regeneration.
 Localized giant pseudopolyposis is considered to result
 from enlarged mucosal tags that become elongated by the
 tractive force of peristalsis and the fecal stream.

Video Endoscopic Sequence 25 of 110.

Rectal ulcers, the colonoscope has returned to the rectum.

Video Endoscopic Sequence 26 of 110.

Multiple Rectal Ulcers

Video Endoscopic Sequence 27 of 110.

 The histological features of ulcerative colitis parallel the
 endoscopic appearance of a diffuse, continuous pattern of
 superficial inflammation within the involved mucosal
 segments and normal proximal mucosa. The principle
 components are disruption of glandular architecture and
 an inflammatory infiltrate. While there are no
 pathognomonic histological criteria for the diagnosis of
 ulcerative colitis.

Video Endoscopic Sequence 28 of 110.

 Endoscopic biopsies are crucial in the initial evaluation of
 ulcerative colitis, to accurately exclude self-limited colitis,
 and to differentiate ulcerative colitis from Crohn's disease.
 Histologic findings in early stages of ulcerative colitis are
 characterized by mucosal infiltration by acute inflammatory
 cells, including neutrophils, lymphocytes, plasma cells, and
 macrophages. Neutrophilic infiltration of crypts leads to
 cryptitis and crypt abscesses. Due to the nonspecific
 inflammatory findings, it may be difficult to distinguish
 ulcerative colitis from acute colitis at this stage.

Video Endoscopic Sequence 29 of 110.

 A primary distinction between chronic inflammatory bowel
 disease such as ulcerative colitis and acute self-limited
 (infectious) colitis is architectural distortion. In ulcerative
 colitis, the normal vertical (“test-tube”) alignment of glands
 is distorted and, often branched or irregularly shaped. The
 glands are separated by expanded lamina propria
 lymphocytes, plasma cells, and eosinophils, as well as by
 neutrophils, which are normally sparse. The neutrophilic
 infiltrate is localized to the base of the glandular crypts
 and invades the crypts, producing crypt abscesses. In more
 severe disease, the epithelial lining is destroyed, with
 denuding ulcerations over the lamina propria.

Video Endoscopic Sequence 30 of 110.

 Our patient presents edema of lower extremities clinical
 sign which be considered in all patient with ulcerative
 colitis as a serious stage. (Severe ulcerative colitis).

 Our patient presents

• Edema of lower extremities clinical sign that should be considered in every patient with ulcerative colitis as severe
• There was hipoalbuminemia and scarce ascitis to the moment of the first hospitalization.

Video Endoscopic Sequence 31 of 110.

Pitting Edema

 Severe ulcerative colitis: hypoalbuminemia resulting from
 low protein intake (anorexia) and increased chronic loss of
 albumin are hallmarks of this form of the disease.

Video Endoscopic Sequence 32 of 110.

Computed Tomography Scout View

 Panoramic view in the first hospitalization that was taken
 in the second day which is observed clearly marked that
 the walls of the colon are thick.

 In the first abdominal CT scan a thickening of the
 descending colon, just belowthe splenic flexure, was seen,
 with the question of malignancy.

  Click on the Rx image to enlarge

Video Endoscopic Sequence 33 of 110.

Computed Tomography Scout View

 Computed tomography scout view is a mode of operating a
 CT system. It is generally used to prescribe CT slices and
 to display slice locations rather than for direct diagnosis.
 However, a careful study of CT scout view can contribute
 significantly to the diagnosis.

Click on the Rx. Image to enlarge

Video Endoscopic Sequence 34 of 110.

Second Hospitalization

 After 10 days of ambulatory treatment and 18 after the
 colonoscopy, the patient is readmitted to the hospital
 because of increased abdominal pain and sepsis. WB
 counts: 21,900 with 98% neutrophils, with a hemoglobin of
 10 g/dl. The second day, patient presents with hypotension,
 tachycardia and signs of tissue hypoperfusion those sign
 are consistent of toxic megacolon .

 The patient underwent emergency surgery
 (Colectomy with ileostomy).

Cyanosis of the extremities

 Clinically, the patient with toxic megacolon presents as
 severely ill with a fever, tachycardia, dehydration,
 abdominal pain and distention). Examination reveals
 absent bowel sounds, tympany and rebound tenderness.
 Leukocytosis (greater than 10,000), anemia and
 hypoalbuminemia are often present. A plain x-ray of the
 abdomen will reveal dilation of a colonic segment or of the
 entire colon. On plain supine x-ray, dilation of the
 transverse colon is most often seen. This distention of the
 transverse colon does not indicate severity of disease in
 this segment of the colon; rather, the distention is
 determined by the anterior position of the transverse colon.
 Repositioning the patient to a prone position will
 redistribute the gas to the more posterior descending colon
 and will dramatically decrease gaseous tension in the
 transverse colon.

Video Endoscopic Sequence 35 of 110.

Cyanosis Distal

 The patient's clinical condition deteriorated over the next
 18 hours despite steroid and antibiotic therapy, and the
 patient had to undergo total colectomy and ileostomy.

 The diagnosis of toxic megacolon is based on clinical
 findings, simple laboratory results, and a careful scrutiny of
 the plain abdominal radiograph. Usually, no other radiologic
 investigations are required. Once toxic megacolon is
 diagnosed, the patient must be immediately admitted to an
 intensive care unit where he or she can be monitored by
 intensivists and a team of physicians and surgeons. The
 mortality rate is high, at 20%.

Video Endoscopic Sequence 36 of 110.

Plain Abdominal Rx

 DIAGNOSIS — The diagnosis of toxic megacolon should
 be considered in all patients presenting with abdominal
 distension and acute or chronic diarrhea. The diagnosis is
 clinical, based upon the finding of an enlarged dilated colon
 accompanied by severe systemic toxicity. The initial
 evaluation should be aimed at establishing the diagnosis of
 toxic megacolon and at determining the underlying etiology
 to help institute specific therapeutic measures.

Video Endoscopic Sequence 37 of 110.

 Toxic megacolon is defined as a severe episode of colitis
 with segmental or total dilatation of the colon. It is typically
 a complication of ulcerative colitis, but it may be a
 complication of Crohn disease, antibiotic-related
 pseudomembranous colitis, and other colitides.
 Pathologically, acute fulminant colitis is associated with
 neuromuscular degeneration and a rapid and extensive
 colonic dilatation.

Video Endoscopic Sequence 38 of 110.

 Computed Tomography Scout View in the second day of the second hospitalization

 Toxic megacolon is a potentially lethal complication of
 inflammatory bowel disease (IBD) or infectious colitis that
 is characterized by total or segmental nonobstructive
 colonic dilatation plus systemic toxicity.

 Toxic megacolon is characterized by an acute dilation of all
 or part of the colon to a diameter greater than 6 cm.
 (measured in the mid-transverse colon) and is associated
 with severe systemic toxicity. Toxic megacolon occurs in
 1– 2% of patients with ulcerative colitis. Histological
 examination reveals extensive deep ulcerations and acute
 inflammation that involves all muscle layers of the colon
 and often extends to the serosa. This widespread
 inflammation accounts for toxic megacolon’s systemic
 toxicity (fever, tachycardia, localized abdominal pain and
 leukocytosis). The loss of colonic muscular tone results in
 the dilation of the colon.

Video Endoscopic Sequence 39 of 110.

 CT is valuable for the detection and characterization of
 ulcerative colitis. CT typically demonstrates
 circumferential, symmetrical wall thickening with fold
 enlargement. Thickening of the colon wall (mean, 7.8 mm;
 standard deviation, 1.9) may be present, with
 inhomogeneous attenuation, a target appearance of the
 rectum, and the proliferation of perirectal fat. The normal
 colonic wall has a maximal thickness of 3 mm with the
 lumen distended and 5 mm with the lumen collapsed. In
 comparison, Crohn colitis causes greater bowel wall
 thickening (mean, 11 mm; standard deviation, 5.1). Such
 thickening appears in association with homogeneous
 attenuation, fistula and abscess formation, and mesenteric
 abnormalities.

 Click here or in the image to enlarge

Video Endoscopic Sequence 40 of 110.

 Patients with toxic megacolon often present in the
 emergency department as having abdominal distention
 superimposed on chronic or acute diarrhea. The diagnosis
 should be considered in all such patients. The diagnosis is
 usually based on thorough clinical history taking and
 physical examination combined with plain abdominal
 radiography. CT has a limited role, although it better
 depicts the anatomic detail of transmural disease,
 mesenteric involvement, and intraperitoneal complications
 of inflammatory bowel disease.

Video Endoscopic Sequence 41 of 110.

 Bowel thickening is a nonspecific finding; it may be
 encountered in a variety of colitides and other pathologies
 of the bowel wall. The target sign is also nonspecific; it has
 been reported in Crohn colitis. Mucosal ulceration
 is difficult to detect with CT.

Video Endoscopic Sequence 42 of 110.

 Click here or in the image to enlarge

Video Endoscopic Sequence 43 of 110.

 Toxic megacolon is the most severe manifestation of
 ulcerative colitis, diagnosed when the inflammation extends
 from the superficial mucosa into the submucosal and
 muscular layers of the colon. Toxic megacolon occurs more
 commonly in the setting of extensive colitis but can also
 occur with severe distal colitis. The manifestations of toxic
 megacolon include: fever, prostration, severe cramps,
 abdominal distention, and abdominal tenderness that may
 be localized, diffuse, or associated rebound tenderness.
 These toxic manifestations result from transmural
 extension of inflammation producing circular muscle
 paralysis and precipitating dilation along with a
 “tissue-paper” thin colonic wall.

Video Endoscopic Sequence 44 of 110.

Video Endoscopic Sequence 45 of 110.

Video Endoscopic Sequence 46 of 110.

Video Endoscopic Sequence 47 of 110.

 Download the video clip by clicking on the image

Video Endoscopic Sequence 48 of 110.

 Although many CT findings in ulcerative colitis are striking,
 they are not considered specific. Some features do suggest
 a diagnosis of IBD, and specific features may indicate a
 single diagnosis of ulcerative colitis with a high degree of
 confidence. The halo sign typically occurs in ulcerative
 colitis.

 Download the video clip by clicking on the image

Video Endoscopic Sequence 49 of 110.

 Image and video clip where is observed the perforation in
 the transverse colon

 Perforation and toxic megacolon are the most dreaded
 complications of UC. Perforation can occur in the presence
 of fulminating disease, even in the absence of toxic
 megacolon. The mortality rate is 50% if perforation occurs.

 Surgical intervention with colectomy is indicated in patients
 who are intractable to medical therapy and for those with
 massive hemorrhage, colonic perforation, unresolving toxic
 megacolon, and dysplasia or carcinoma.

 Download the video clips by clicking on the images

Video Endoscopic Sequence 50 of 110.

Suturing to be avoided major contamination during the surgery.

Video Endoscopic Sequence 51 of 110.

 Emergency surgery involves total colectomy and end
 ileostomy as a life-saving procedure. Patients presenting
 with severe acute colitis for their first attack are the most
 likely to require colectomy (up to 25%). Following recovery
 from a total colectomy, thought must be given to the fate
 of the remaining rectum as it can continue to cause bloody
 anal discharge if the inflammation fails to subside and it
 remains a site of potential cancer, although the risk is
 about 5% over 20 years. There are four options for the
 residual rectum:

 Elective

 In the elective situation there are three surgical options:
 1. Panproctocolectomy and end ileostomy
 2. Total colectomy and ileorectal anastomosis
 3. Panproctocolectomy and ileal pouch–anal anastomosis

 The choice of operation depends on patient fitness,
 sphincter function and choice. All three elective procedures
 can now be carried out with laparoscopic assistance.

Video Endoscopic Sequence 52 of 110.

Ileostomy

 Both fulminant colitis and toxic megacolon are regarded as
 the sequelae of colitis in which irreversible changes in the
 whole thickness of colonic wall have occurred. These
 condition both call for an immediate, emergent surgical
 intervention. Until recently the procedure of choice in this
 acute phase of the disease was colectomy with Brooke
 ileostomy and Hartmann type closure of the distal rectum.
 Colectomy with ileal pouch anal anastomosis was reserved
 only for elective surgery.

Pubmed: Surgical procedure in fulminant colitis and toxic megacolon

Video Endoscopic Sequence 53 of 110.

 The improvement in surgical technique, but first of all
 widespread of stapling devices, have shortened the time of
 operation and simplified the procedure, so that creation of
 an ileal reservoir is currently more often performed as a
 one step procedure and without an increased risk.

 Pubmed: Current surgical therapy for mucosal ulcerative
 colitis.

Video Endoscopic Sequence 54 of 110.

Gross Description:

 Colon of 95 cm with 8 cm of diameter at the level of the
 cecum, 6 cm. in the transverse and descending colon 5 cm.
 in their averages diameters. At the level of transverse
 mesocolon there were purulent exudate at site of two
 stitches of silk in area of perforacion of 1.2 cm long.

 Panoramic view of the surgical specimen showing the entire
 colon which was resected from the recto-sigmoid junction to
 20 cm of terminal ileum

Twenty percent of patients require colectomy, which is curative.

Video Endoscopic Sequence 55 of 110.

The cut of the surgical piece begins.

 Surgical intervention with colectomy is indicated in
 patients who are intractable to medical therapy and for
 those with massive hemorrhage, colonic perforation,
 unresolving toxic megacolon, and dysplasia or carcinoma.

See the video clip

Video Endoscopic Sequence 56 of 110.

We continue with the cut of the surgical piece

 The most widely used criteria for the clinical diagnosis of
 toxic megacolon are: Radiographic evidence of colonic
 distension PLUS at least three of the following: Fever
 >38şC Heart rate >120 beats/min Neutrophilic leukocytosis
 >10,500/microL Anemia PLUS at least one of the
 following: Dehydration Altered sensorium Electrolyte
 disturbances Hypotension.

 Download the video clip by clicking on the image

Video Endoscopic Sequence 57 of 110.

The Cecum

 Rapid development of ulcerative colitis with
 pseudopolyposis in the ascending colon and cecum

 There are multiple ulcers and pseudopolyps that was not
 seen in the colonoscopy performed 18 days before, that
 indicates the inflammatory process was progressive in
 spite of the treatment with high doses of prednisona.

 Pubmed: Total abdominal colectomy and ileorectal anastomosis
 for inflammatory bowel disease.

Video Endoscopic Sequence 58 of 110.

 The ileocecal valve has been opened, being observed some
 centimeters of the terminal ileum.

 Download the video clip by clicking on the image

Video Endoscopic Sequence 59 of 110.

The ileocecal valve with a portion of terminal ileum that is not involved.

 Ulcerative colitis is confined to the large bowel although up
 to 30 cm of terminal ileum can be involved with “backwash
 ileitis”

 Mural thickening of the terminal ileum may be visualized
 in 10-25% of patients; such thickening is caused
 by backwash ileitis, which occurs as a result of the reflux
 of colonic contents into the distal ileum. Abscesses and
 pseudodiverticula are not features of ulcerative colitis;
 they occur almost exclusively in Crohn colitis.

Video Endoscopic Sequence 60 of 110.

 The treatment of ulcerative colitis in both the acute and
 chronic phases of the disease is rather difficult. There is
 uniform agreement that these patients should be treated
 medically as long as they show improvement and continue
 in a satisfactory condition. It should be admitted, however,
 that some patients do not respond satisfactorily to any or
 all of the medical measures that may be employed.  

Video Endoscopic Sequence 61 of 110.

Download the video clip by clicking on the image

Pubmed: Outcome of ileorectal anastomosis in an inflammatory bowel disease surgery experience of three decades.

Video Endoscopic Sequence 62 of 110.

Extensive Pseudopolyposis

 At section  there were islands or pseudopolyps of mucosa,
 red dark, a lot with ulceration and perforation at the level
 of the transverse colon (sutures site). at the cecum the
 injuries were less severe retaining areas of edematous
 and hiperemic mucosa  with irregular ulcers.  The
 pseudopolyps varied between 0.5 and 2 cm diameter.
 There were appreciated multiple hemorragic areas and
 yellowish material on the islands of mucosae and ulcerated
 zones.  The ileocecal valve was edematous.

More details download the video clip clicking on the image

Video Endoscopic Sequence 63 of 110.

The opened colon shows numerous enlarged or elongated polyps

 Ulcerative Colitis (UC).

 Generalized polyposis, generally considered to be an
 asymptomatic sequela of ulcerative colitis, can also be
 associated with severe attacks of colitis.

Video Endoscopic Sequence 64 of 110.ç

Extensive ulcerative colitis (UC) with pseudopolyposis

 The severity of the inflammatory reaction seen correlates
 well with the clinical course of the disease. Most of the
 cardinal features of UC include:

• Inflammation limited to the mucosa and superficial
  submucosa although deeper layers can be involved in
  fulminant colitis.
• Diffuse and severe distortion of crypt architecture,
  although this can take 6/52 to develop.
• Diffuse and severe reduction in crypt density.
• Heavy infiltration of inflammatory cells in the
  lamina propria. In active disease neutrophils are
  prevalent and these can form crypt abscesses which
  are a reliable indicator of disease severity.
• Severe mucin depletion.
• Superficial ulceration in active disease.

Video Endoscopic Sequence 65 of 110.

 The opened resected specimen of the colon with dilatation
 and extensive ulcerations and pseudopolyposis.

 Inflammation with ulcerative colitis tends to be continuous
 along the mucosal surface and tends to begin in the rectum.
 The mucosa becomes eroded, as in this photograph, which
 shows only remaining islands of mucosa called
 "pseudopolyps".

 Download the video clip by clicking on the image

Video Endoscopic Sequence 66 of 110.

Approach to the pseudopolyps and the extensive ulcers

 At higher magnification, the pseudopolyps can be seen
 clearly as raised red islands of inflamed mucosa. Between
 the pseudopolyps is only remaining muscularis.

See the video clip.

Video Endoscopic Sequence 67 of 110.

 Pseudopolyps are seen here in a case of severe ulcerative
 colitis. The remaining mucosa has been ulcerated away
 and is hyperemic. A colonoscopic view of active ulcerative
 colitis, but not so eroded as to produce pseudopolyps.

 Download the video clip by clicking on the image

Video Endoscopic Sequence 68 of 110.

 The clinical severity of ulcerative colitis depends on both
 the length of colon involved and the severity of colonic
 inflammation.

 The symptomatic criteria most commonly used to define the
 severity of disease were established by Truelove and Witts
 to assess improvement in the first clinical trial of cortisone
 for ulcerative colitis and remain useful to classify severity
 in clinical practice. The criteria define mild and severe
 disease activity with moderate activity being present when
 there are intermediate symptoms. These criteria may also
 be modified to include fulminant colitis.

 Most patients present with moderately severe symptoms of
 ulcerative colitis and the course is, typically, intermittent
 with the majority of patients maintained in clinical
 remission or having mild symptoms despite a 90%
 likelihood of relapse if medical therapy is not maintained.

Video Endoscopic Sequence 69 of 110.

Another picture of the surgical specimen from the rectosigmoid juntion to the terminal ilium.

Download the video clip by clicking on the image.

Video Endoscopic Sequence 70 of 110.

Download the video clip

 Mural thickening is a common manifestation of
 inflammatory bowel disease; in general, however,
 ulcerative colitis produces less wall thickening than does
 Crohn disease.

Video Endoscopic Sequence 71 of 110.

Photographic Gallery

Macroscopic appearance of the resected colon

The following pictures can be enlarge by clicking on them

Video Endoscopic Sequence 72 of 110.

Colectomy Specimen

 The cecal appendix average 7x0.5 cm with hyperemia,
 the lumen was reduced. The ileon were 16 cm. long and
 2 cm. in diameter. The mucosae shows edema and erosions.
 Ileocecal ganglia were hyperemics.

Video Endoscopic Sequence 73 of 110.

 This picture shows the surgical incision of the recto-sigmoid junction.

Video Endoscopic Sequence 74 of 110.

Colectomy Specimen

 Gross examination of the large intestine in non-neoplastic
 conditions can also yield valuable diagnostic information,
 particularly in the classification of inflammatory bowe
 disease.

 Click on image to view larger version.

Video Endoscopic Sequence 75 of 110.

Macroscopic Description

 The distribution, extent, and nature of macroscopic
 changes in inflammatory bowel disease are frequently
 important diagnostic features. The following guidelines
 primarily relate to resections performed for Crohn's
 disease and ulcerative colitis. The specimen nature (extent
 of surgical resection) should be recorded. Care should be
 taken to identify and document the distribution of serosal
 fat wrapping, severe dilatation, mural thickening or
 stricture formation, ulcers, perforation, pseudopolyps, and
 mucosal cobblestoning. Both ulcerative colitis and Crohn's
 disease are associated with an increased risk of colorectal
 cancer, and specimens should be examined carefully for
 any suspicious lesions.

Video Endoscopic Sequence 76 of 110.

This pictute shows the site of perforation

 Thorough macroscopic descriptions have a tendency to
 become lengthy, and specimen photography can prove
 extremely useful in this situation, providing an invaluable
 visual record for clinicopathological meetings. The
 appearance of fixed specimens can be improved by
 immersing in 70% ethyl alcohol for colour restoration
 before being photographed.

Video Endoscopic Sequence 77 of 110.

Again the site of perforation

Video Endoscopic Sequence 78 of 110.

The silk suturing where is the site of perforation

Video Endoscopic Sequence 79 of 110.

Video Endoscopic Sequence 80 of 110.

Video Endoscopic Sequence 81 of 110.

Video Endoscopic Sequence 82 of 110.

Images show total colitis and extensive pseudopolyposis.

Video Endoscopic Sequence 83 of 110.

 Polypoid and pseudopolypoid manifestations of
 inflammatory bowel disease. (pubmed).

 The polypoid manifestations of the idiopathic inflammatory
 bowel diseases (ulcerative colitis and Crohn disease) are
 often confusing. Inflammatory polyps project above the
 level of the surrounding mucosa. Pseudopolyposis
 (in ulcerative colitis) or a cobblestone appearance
 (in Crohn disease) results when extensive ulceration
 develops and only scattered islands of relatively normal
 mucosa remain; thus, the ulcerated areas may be falsely
 perceived as the baseline and the islands as polyps.
 Postinflammatory (filiform) polyps--fingerlike projections
 of submucosa covered by mucosa on all sides--reflect
 healing of undermined mucosal and submucosal remnants
 and ulcers and are almost always multiple. Patients with
 ulcerative colitis or Crohn disease are at increased risk for
 developing adenocarcinoma.

Video Endoscopic Sequence 84 of 110.

 Occasionally, dysplasia occurs as a polypoid lesion.
 Dysplasia of the colon (mucosal atypia) is a histologic
 marker highly associated with adenocarcinoma. Because
 differentiating adenocarcinoma and dysplasia from
 inflammatory or postinflammatory polyps is sometimes
 difficult or impossible, endoscopy and biopsy are usually
 recommended for definitive diagnosis of suspicious lesions.

Video Endoscopic Sequence 85 of 110.

Image of Surgical Specimen: multiple and extensive pseudopolyposis in ulcerative colitis.

Video Endoscopic Sequence 86 of 110.

View of Surgical Specimen: multiple and extensive pseudopolyposis in ulcerative colitis.

Video Endoscopic Sequence 87 of 110.

 Photograph shows continuous regions of ulceration and
 pseudopolyps throughout the total colectomy specimen,
 with the most severe changes evident in the ascending and
 transverse colon portions, and dilatation indicative of
 megacolon.

Video Endoscopic Sequence 88 of 110.

 Pseudopolyposis is probably the most common local
 complication of ulcerative colitis. The reported incidence
 varies from 12,5% to 74%, depending on the diagnostic
 criteria employed and patients groups studied.
 Pseudopolyps represent polypoid edematous mucosal tags,
 regenerative mucosal islands between areas of ulceration
 or heaped-up granulation tissue covered by glandular
 epithelium (Dukes, 1954). They may be seen in the active
 or quiescent phase of the disease and can be diffuse or
 local in distribution. There is a direct relation between
 severity and extension of the disease and the incidence of
 pseudopolyposis, although the outcome of severe attacks
 of ulcerative colitis in the presence of pseudopolyps has
 been found to be more favourable.

Video Endoscopic Sequence 89 of 110.

 Inflammatory Pseudopolyposis following a chronic severe
 case of ulcerative colitis.

 The majority of evidence supports the concept that
 pseudopolyposis per se is not a precancerous change and
 the discovery of pseudopolyps in itself does not require
 any specific treatment

 Click on the image to enlarge in a new windows

Video Endoscopic Sequence 90 of 110.

Image of Surgical Specimen: multiple and extensive pseudopolyposis in ulcerative colitis.

Video Endoscopic Sequence 91 of 110.

 Although pseudopolyps are the commonest sequelae of
 ulcerative colitis, the occurrence of localized exuberant
 collections of pseudopolyps, giving rise to large
 intraluminal masses, is a rare finding during the course of
 the disease. The term ‘‘Localized giant pseudopolyposis
 has been applied to describe this phenomenon.

Video Endoscopic Sequence 92 of 110.

Video Endoscopic Sequence 93 of 110.

Video Endoscopic Sequence 94 of 110.

Video Endoscopic Sequence 95 of 110.

Video Endoscopic Sequence 96 of 110.

Video Endoscopic Sequence 97 of 110.

Video Endoscopic Sequence 98 of 110.

Video Endoscopic Sequence 99 of 110.

This image as well as the video clip was taken by the pathologist

Video Endoscopic Sequence 100 of 110.

To enlarge the image click on it

Video Endoscopic Sequence 101 of 110.

Video Endoscopic Sequence 102 of 110.

 There are severe inflammatory process with extensive
 ulcerations leaving islands or pseudopolyps of mucosa with
 of granulacion tissue.  there are extensive areas of
 hiperemic and hemorragic tissue. there are microabsces
 and purulent surface and in the ulcers.

 Click here or in the image to enlarge image

Video Endoscopic Sequence 103 of 110.

 The inflamatory  process goes deep into the own muscle
 and pericolic adiposse tissue with perforacion at the level
 of the transverse colon. the cecal appendix has chronic
 inflamation similar to the ileal mucosa with erosions. 

 The lymphonodes have chronic inflamacion. The ileal limit
 has chronic inflamation. The surgical limit at the sigmoid
 end has chronic inflamation and is extensively ulcerated.
 

Video Endoscopic Sequence 104 of 110.

Video Endoscopic Sequence 105 of 110.

Video Endoscopic Sequence 106 of 110.

Video Endoscopic Sequence 107 of 110.

Video Endoscopic Sequence 108 of 110.

Video Endoscopic Sequence 109 of 110.

Video Endoscopic Sequence 110 of 110.