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Page: Clinical Presentation
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GI symptoms
The clinical presentation of ulcerative colitis depends on the extent of the disease process. Patients usually present with diarrhea mixed with blood and mucus, of gradual onset. They also may have signs of weight loss, and blood on rectal examination. The disease is usually accompanied with different degrees of abdominal pain, from mild discomfort to severely painful cramps.
Ulcerative colitis is a systemic disease that affects many parts of the body. Sometimes the extra-intestinal manifestations of the disease are the initial signs, such as painful, arthritic knees in a teenager. It is, however, unlikely that the disease will be correctly diagnosed until the onset of the intestinal manifestations.
Extent of involvement
Ulcerative colitis is normally continuous from the rectum up the colon. The disease is classified by the extent of involvement, depending on how far up the colon the disease extends:
* Distal colitis, potentially treatable with enemas:
o Proctitis: Involvement limited to the rectum.
o Proctosigmoiditis: Involvement of the rectosigmoid colon, the portion of the colon adjacent to the rectum.
o Left-sided colitis: Involvement of the descending colon, which runs along the patient's left side, up to the splenic flexure and the beginning of the transverse colon.
* Extensive colitis, inflammation extending beyond the reach of enemas:
o Pancolitis: Involvement of the entire colon, extending from the rectum to the cecum, beyond which the small intestine begins.
[edit] Severity of disease
In addition to the extent of involvement, UC patients may also be characterized by the severity of their disease.
* Mild disease correlates with fewer than four stools daily, with or without blood, no systemic signs of toxicity, and a normal erythrocyte sedimentation rate (ESR). There may be mild abdominal pain or cramping. Patients may believe they are constipated when in fact they are experiencing tenesmus, which is a constant feeling of the need to empty the bowel accompanied by involuntary straining efforts, pain, and cramping with little or no fecal output. Rectal pain is uncommon.
Moderate disease correlates with more than four stools daily, but with minimal signs of toxicity. Patients may display anemia (not requiring transfusions), moderate abdominal pain, and low grade fever, 38 to 39 °C (99.5 to 102.2 °F).
* Severe disease, correlates with more than six bloody stools a day, and evidence of toxicity as demonstrated by fever, tachycardia, anemia or an elevated ESR.
* Fulminant disease correlates with more than ten bowel movements daily, continuous bleeding, toxicity, abdominal tenderness and distension, blood transfusion requirement and colonic dilation (expansion). Patients in this category may have inflammation extending beyond just the mucosal layer, causing impaired colonic motility and leading to toxic megacolon. If the serous membrane is involved, colonic perforation may ensue. Unless treated, fulminant disease will soon lead to death.
Extraintestinal features
As ulcerative colitis is a systemic disease, patients may present with symptoms and complications outside the colon. These include the following:
* aphthous ulcers of the mouth
* Ophthalmic (involving the eyes):
o Iritis or uveitis, which is inflammation of the iris
o Episcleritis
* Musculoskeletal:
o Seronegative arthritis, which can be a large-joint oligoarthritis (affecting one or two joints), or may affect many small joints of the hands and feet
o Ankylosing spondylitis, arthritis of the spine
o Sacroiliitis, arthritis of the lower spine
* Cutaneous (related to the skin):
o Erythema nodosum, which is a panniculitis, or inflammation of subcutaneous tissue involving the lower extremities
o Pyoderma gangrenosum, which is a painful ulcerating lesion involving the skin
* Deep venous thrombosis and pulmonary embolism
* autoimmune hemolytic anemia
* clubbing, a deformity of the ends of the fingers
* Primary sclerosing cholangitis, or inflammation of the bile duct
Similar conditions
The following conditions may present in a similar manner as ulcerative colitis, and should be excluded:
* Crohn's disease
* Infectious colitis, which is typically detected on stool cultures
o Pseudomembranous colitis, or Clostridium difficile-associated colitis, bacterial upsets often seen following administration of antibiotics
* Ischemic colitis, inadequate blood supply to the intestine, which typically affects the elderly
* Radiation colitis in patients with previous pelvic radiotherapy
* Chemical colitis resulting from introduction of harsh chemicals into the colon from an enema or other procedure.
Comparison to Crohn's Disease
The most common disease that mimics the symptoms of ulcerative colitis is Crohn's disease, as both are inflammatory bowel diseases that can affect the colon with similar symptoms. It is important to differentiate these diseases, since the course of the diseases and treatments may be different. In some cases, however, it may not be possible to tell the difference, in which case the disease is classified as indeterminate colitis.
Comparisons of various factors in Crohn's disease and ulcerative colitis Crohn's Disease Ulcerative Colitis
Involves terminal ileum? Commonly Seldom
Involves colon? Usually Always
Involves rectum? Seldom Usually
Peri-anal involvement? Commonly Seldom
Bile duct involvement? Not associated Higher rate of Primary sclerosing cholangitis
Distribution of Disease Patchy areas of inflammation Continuous area of inflammation
Endoscopy Linear and serpiginous (snake-like) ulcers Continuous ulcer
Depth of inflammation May be transmural, deep into tissues Shallow, mucosal
Fistulae, abnormal passageways between organs Commonly Seldom
Biopsy Can have granulomata
Surgical cure? Often returns following removal of affected part Usually cured by removal of colon
Smoking Higher risk for smokers Lower risk for smokers
Autoimmune disease? Generally regarded as an autoimmune disease No consensus
Cancer risk? Lower than ulcerative colitis Higher than Crohn's
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Important notice:
The content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other
qualified health provider with any questions you may have regarding a medical condition.
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