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Ulcerative Colitis:
“Condition of severe non-specific inflammation of the colon associated with various degrees of ulcerations”
Pathology:
The onset and progress of ulcerative colitis almost always starts in rectum and extends proximally. Sometimes whole colon is involved sooner or later. If ileocecal valve is incompetent then retrograde extension to the terminal ileum occurs. In some cases skip lesions are also seen in colon. In any case the distal part of the colon nearly always shows pathology at its maximum.
Macroscopic Appearance:
- There is swelling, oedema and congestion of the mucous membrane associated with minute ulcers. Ulcers may be few and far between or there may be “sea of ulcers”. Ulcers are shallow and irregular, which slough adherent to their floor. Pin-Point abscesses are also visible in the depth of mucous membrane.
- As the disease progresses and extends along the length of the colon, the severity of ulceration and underlying pathology also increases. The mucous membrane becomes bright and purple associated with purpuric haemorrhages. The small ulcers coalesce to form big ulcerations because crypts of Luberkuhn become distended with pus and burst into the bowel. The big ulcers may be round or linear but usually are irregular in shape with undetermined irregular margins. The mucous membrane in between the ulcers is usually swollen and oedematous. In many cases mucous tags having the pattern of polyps are found to be hanging called psuedopolyps and are caused by the epithelial thickening, resulting from attempt at healing. In advanced cases ulcers are so numerous and huge (extensive) that wide areas of colon appear to be denuded of mucosa.
As the ulcer gets deeper and extends into submucosa, they cause reflux muscular spasm giving the appearance of strictures. In long standing cases, actual fibrosis occurs in the wall of colon. The colon now becomes thick walled and rigid. It loses its normal sacculation, becomes smaller than normal, both in calibre and length. The lymph nodes in the mesocolon are enlarged but mesocolon remains thin, devoid of fat.
Clinical Features:
The disease starts suddenly. Sudden attack of diarrhoea occurs day and night. Stools are watery but blood stained. Rectal discharge is commonly mucoid but sometimes purulent. Pain is usually absent
In acute fulminating type (5%)
diarrhoea, stool containing blood, mucous and pus are prominent. Abdominal distension due to acute dilation of colon is obvious. Patient is highly toxic and runs temperature.
In chronic and chronic relapsing type (95%)
initial attack is moderately severe. At variable intervals patients get bouts of attack of diarrhoea, which gradually develops from days to months and attacks become more frequent as time passes. There is associated tenesmus. With every episode the patient gets emaciated and anaemic.
Investigation:
- Barium Enema test:
- Pipe stem (colon is narrow and contracted)
- Pseudopolyps (small filling defects)
- Penetration from mucosal layer to muscular layer which results in telltale projections.
- Sigmoidoscopy
- Rectal biopsy
- Straight X-Ray (when barium enema is contraindicated)
Treatment:
Surgical treatment is indicated when there is evidence of active disease or unresponsiveness to drug therapy, when there is risk of developing cancer and when acute bleeding occurs.
Drug Therapy:
- Sulphasalazine (Metasalazine)
- Steroids (prednisolone)
- Immunosuppressive agents
Surgical Interventions:
Nonsphincter sparing procedure:
It may be done in two ways:
- Total colectomy and ileorectal anastomosis
- Total proctocolectomy with iliac pouch and rectal anastomosis
Iliac pouch may be performed in two ways:
S-shaped pouch has greater size and it is easier to approximate this pouch to anus for acute phase. It is reasonable to perform with creation of any kind of anastomosis after removal of affected portion.
Sphincter reservoir procedure/sparing procedure:
It includes total colectomy with cock type ileostomy.
Click here to see the differences between Crohn's Disease and Ulceratice Colitis.
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This article has been written by Dr. M. Javed Abbas.
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