1. Case
A 25-year-old woman
A 4-m history of abdominal pain in the left lower quadrant and bloody diarrhea

2. ？

3. Case Stool Examination: WBC + ,RBC ++
Microbiologic cultures of stools : negative

4. Colonoscopy
A colonoscopic examination involves gently inserting a fiberoptic colonoscope into your rectum and large intestine to view your lower gastrointestinal tract. This video shows a polyp being removed from the wall of the colon.

5. Colonoscopy
Continuous ulcers begin in the rectum

6. Colonoscopy biopsy

7. Pathology crypt abscesses (H/E, 4x) (H/E, 10x)
Low power overview of the colonic lining showing mucosal architectural disarray, colonic gland atrophy and dense inflammatory infiltrate in the lamina propria with presence of crypt abscesses. (H/E, 4x)
Another view showing a crypt abscess with partly destroyed lining of the crypt wall, goblet cell depletion in the mucosal lining and inflamed lamina propria.
(H/E, 4x)
(H/E, 10x)

8. Yan Chen 陈焰 Second Affiliated Hospital
Ulcerative Colitis
Yan Chen 陈焰
Second Affiliated Hospital

9. Concept Idiopathic Inflammatory Bowel Disease Ulcerative colitis(UC)
( IBD)
Ulcerative colitis(UC)
Crohn’s disease (CD)

11. IBD 有关内容

12. Learning Objectives Understand the clinical presentation, and
Understand the current theories of IBD pathogenesis
Understand the clinical presentation, and
management of ulcerative colitis and Crohn’s disease
Understand the fundamental differences between
ulcerative colitis and Crohn’s

13. commendatory websites and books
commendatory books
Harrison’s principles of internal medicine
15th Edition
Goldman: Cecil Medicine, 23rd ed Chapter 144 

14. Ulcerative Colitis (UC)
Concept
Etiology
Pathology
Clinical presentation
Diagnosis and differential diagnosis
Complications
Treatment

15. Concept Ulcerative Colitis
An idiopathic inflammatory disorder involving primarily the mucosa and submucosa of the colon
especially the rectum
often with mucosal erosions and ulcers

16. Concept colitis confined colitis up to rectum (proctitis)
rectum and sigmoid colon (proctosigmoiditis)
splenic flexure (left sided colitis)
colitis up to
the hepatic flexure (extensive colitis)
the whole colon (pancolitis)

17. Concept

18. Ulcerative Colitis (UC)
Concept
Etiology
Pathology
Clinical presentation
Diagnosis and differential diagnosis
Complications
Treatment

19. Etiologic Theories in IBD
Genetic Predisposition
Mucosal Immune System
(Immuno-regulatory Defect)
IBD
Environmental
Triggers
(Lumenal Bacteria, Infection)
Clinical and basic research in inflammatory bowel disease has suggested that three factors are critically important in the development of inflammatory bowel disease in the a given individual. First, patients inherit genes that predispose to inflammatory bowel disease. These genes may result in abnormalities in the mucosal immune system such as overproduction of pro-inflammatory cytokines or under-production of anti-inflammatory or regulatory cytokines. Finally, a triggering event must occur to set in motion the chronic inflammation. This triggering event is generally believed to be bacteria but may include other environmental factors such as smoking or NSAIDS.
Susceptibility is inherited, polygenic (effects on barrier function, immunoregulation
Exaggerated T cell response to commensal bacteria

20. Ulcerative Colitis (UC)
Concept
Etiology
Pathology
Clinical presentation
Diagnosis and differential diagnosis
Complications
Treatment

21. Pathology Tends to begin in the rectum and be continuous
Limited inflammation
Mucosa and submucosa
Crypt abscess

22. Pathology Tends to be continuous along the mucosal surface;
Tends to begin in the rectum.
The most intense inflammation begins at the lower right in the sigmoid colon and extends upward and around to the ascending colon. At the lower left is the ileocecal valve with a portion of terminal ileum that is not involved. 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".

23. Pathology Tends to begin in the rectum and be continuous
Limited inflammation
Mucosa and submucosa
Crypt abscess

25. Normal colon

26. Ulcerative colitis

27. Pathology Tends to begin in the rectum and be continuous
Limited inflammation
Mucosa and submucosa
Crypt abscess: Characteristic finding

28. Characteristic finding Crypt abscess

30. Pathology Tends to begin in the rectum and be continuous
Limited inflammation
Mucosa and submucosa
Crypt abscess

31. Ulcerative Colitis (UC)
Concept
Etiology
Pathology
Clinical presentation
Diagnosis and differential diagnosis
Complications
Treatment

32. Clinical presentation
variable
Bloody diarrhea hallmark
Abdominal pain
Fecal urgency
Tenesmus

33. U C Mild Moderate Severe Bowel movements <4/d 4-6/d >6/d
Blood in stool Small Moderate Severe
Fever None <37.5℃ >37.5℃
Tachycardia None < >90
Anemia Mild Moderate Severe
ESR <30mm >30mm
Endoscopic Erythema Marked Erythema Spontaneous
appearance contract bleeding bleeding,
ulcerations
On the basis of several clinical and lab parameters,it is useful to classify patients as having mild,moderate and severe disease.

34. extraintestinal manifestation
Pyoderma gangrenosum
Ocular complications of IBD are uveitis 眼色素层炎,葡萄膜炎 and episcleritis
The two common dermal complications of IBD are pyoderma gangrenosum and erythema nodosum
Arthritis
Erythema nodosum
Episcleritis

35. Ulcerative Colitis (UC)
Concept
Etiology
Pathology
Clinical presentation
Diagnosis and differential diagnosis
Complications
Treatment

36. Diagnosis Essentials of Diagnosis Bloody diarrhea
Lower abdominal pain and fecal urgency
Anemia,low serum albumin
Negative stool cultures
Colonoscopy is key to diagnosis
Imaging is helpful sometimes

37. Laboratory finding Negative stool cultures Anemia, ESR,CRP
low serum albumin
p-ANCA: 70% positive

38. Negative stool cultures
Very important

40. Imaging
Plain abdominal
Barium enemas

41. Plain abdominal
Severe patients
colonic dilation
Toxic megacolon

42. Diagnosis Essentials of Diagnosis Bloody diarrhea
Lower abdominal pain and fecal urgency
Anemia,low serum albumin
Negative stool cultures
Colonoscopy is key to diagnosis
Imaging is helpful sometimes

43. Concept
Etiology
Pathology
Clinical presentation
Diagnosis and differential diagnosis
Complications
Treatment

44. Differential diagnosis
Infectious disease：ameba, dysentery… CD
Colon cancer
IBS
Tub
Ischemic colitis

45. Infections with Shigella, Amoeba, Giardia, Escherichia coli O157:H7, and Campylobacter can be accompanied by bloody diarrhea, cramps, and an endoscopic picture identical to ulcerative colitis
An important distinction between these infectious diseases (except amebiasis) and IBD is that the diarrhea in infectious diseases tends to be limited to a period of days to a few weeks whereas the diarrhea in IBD is typically of longer duration.

46. amebiasis HE stain PAS ： trophozoite
Amebiasis is relatively common in areas of Africa, the Indian subcontinent, and Latin America where sanitation is poor
Entamoeba histolytica exists in two forms: as an active parasite (trophozoite) and as a dormant parasite (cyst).
HE stain
PAS ： trophozoite

47. amebiasis colonscopy amebiasis amebiasis
bacterial pathogens and serologic tests for amebiasis help distinguish infectious diarrhea from IBD.
colonscopy
amebiasis
amebiasis

48. Ulcerative Colitis Crohn Disease Colon only involved Pan-intestinal
Continuous inflammation extending proximally from rectum
Skip-lesions with intervening normal mucosa
Inflammation in mucosa and submucosa only
Transmural inflammation
No granulomas, crypt abscess
Non-caseating granulomas
pANCA positive
pASCA negetive
Bleeding is common
Bleeding is uncommon
Fistulae are rare
Fistulae are common

49. UC CD
Colon only, proximally from rectum
Pan-intestinal, Skip-lesions

50. UC CD
mucosa and submucosa
Transmural
crypt abscess
granulomas

51. CD
Fistulae

52. Ulcerative Colitis (UC)
Concept
Etiology
Pathology
Clinical presentation
Diagnosis and differential diagnosis
Complications
Treatment

53. Complications Toxic megacolon Bleeding Perforation
Risk of colon cancer

54. Toxic megacolon < 2% of cases particularly severe UC
Defined as a severe episode of colitis with segmental or total dilation of the colon (colonic dilation of > 5cm)
Mortality rate : %

55. Toxic megacolon
An acute transmural fulminant colitis with the neurogenic loss of motor tone.
The rapid development of colonic dilatation due to damage to the entire wall of the colon associated with neuromuscular degeneration.

56. Toxic megacolon Diagnosis Clinical findings Laboratory finding
Symptoms  
Signs
Laboratory finding
abdominal plain

57. Clinical findings Symptoms Abdominal pain Abdominal distention Fever
Rapid heart rate
Dehydration
Signs    
Abdominal tenderness
May be signs of septic shock
Possible loss of bowel sounds

58. Lab finding Elevated white blood cell Low potassium level
Abdominal plain shows colonic dilation

59. Toxic megacolon Lower potassium level Barium enema Anticholinergics
Causes
Lower potassium level
Barium enema
Anticholinergics
Drugs used for pain relief

60. Case 1 A 72-year-old woman Vomiting Abdominal distention
History of hypertension and ulcerative colitis

61. Case 1
erect
supine
Picture 5. A 72-year-old woman presented with vomiting and abdominal distention. The supine (right) and erect (left) plain abdominal radiographs show gross dilatation of the colon with multiple air-fluid levels. On further questioning, the patient revealed that she was taking diuretics for hypertension, and blood biochemical tests revealed markedly lowered potassium levels. After potassium replacement therapy, the patient's pseudo-obstruction completely resolved.

62. Toxic megacolon
Cause ？

63. Toxic megacolon
Cause
Lower potassium level after taking diuretics for hypertension

64. Case 2 a 44-year-old man Long history of ulcerative colitis
Double-contrast barium enema

65. Case 2 Double-contrast barium enema
Double-contrast barium enema studies in a 44-year-old man known to have long history of ulcerative colitis. Images show total colitis and extensive pseudopolyposis
Double-contrast barium enema

66. Case 2
2 days later
Picture 2. Plain abdominal radiograph in the same patient as in Image 1, who presented with an acute exacerbation of his symptoms. Image shows thumbprinting in the region of the splenic flexure of the colon.
Plain abdominal radiograph obtained 2 days later in the same patient as in Image 2 shows distention of the transverse colon associated with mucosal edema. The maximum transverse diameter of the transverse colon is 7.5 cm

67. Toxic megacolon Lower potassium level Barium enema Anticholinergics
Causes
Lower potassium level
Barium enema
Anticholinergics
Drugs used for pain relief

68. Complications Toxic megacolon Bleeding Perforation
Risk of colon cancer

69. Cumulative Risk of CRC in UC
% per year after 10 years of disease
Clearly, we know that as with sporadic CRC, if we wait until it becomes symptomatic, then the mortality rate will hover at or about 50%. As for the 2nd assumption, we’ll say “yes” but take a look at the next slide which depicts the variability in CRC, knowing always that the further out we go on the curve, the smaller the denominators become.
Eaden et al. Gut 48:526, 2001

70. Ulcerative Colitis (UC)
Concept
Etiology
Pathology
Clinical presentation
Diagnosis and differential diagnosis
Complications
Treatment

71. Treatment
Guidelines Gut 2004;53:v1-v16 The are should not necessarily be regarded as the standard of care for all patients.
Individual cases must be managed on the basis of all clinical data available for that case
Patient preferences should be sought and decisions jointly made between patient and health professional

72. Treatment
Dependent on the extent of colonic involvement and severity of illness
2 objectives
Inducing remission (periods of time that are symptom-free)
Maintaining remission (preventing flare-ups of disease)

73. Treatment SASP or 5-aminosalicylic acid (5-ASA) Corticosteroids
Immunosuppressive Agents
Azathioprine (AZA) and 6-mercaptopurine (6-MP)
Methotrexate
Cyclosporine
Infliximab
Others
Surgery

74. Sulfasalazine (SASP) Made up of
5-aminosalicylic acid (5-ASA): functionally active moiety of SASP
sulfur molecule: related to the side effects
Newer 5-ASA drugs avoid the side effects

75. newer 5-aminosalicylate–based compounds

76. Corticosteroids control acute inflammatory activity
Topical corticosteroids : ulcerative proctitis or distal ulcerative colitis.
Oral prednisone : moderately severe ulcerative colitis
Intravenous administration: sufficiently ill to require hospitalization;
no maintenance benefit
many and often serious side effects

77. Immunosuppressive Agents
For patients in whom the dose of corticosteroids cannot be tapered or discontinued
Azathioprine or 6-mercaptopurine
Methotrexate
Cyclosporine

78. Absolute and Relative Indications for Surgery
Indications for urgent surgery
Indications for elective surgery
Toxic megacolon refractory to medical management
Chronic steroid dependency
Fulminant attack refractory to medical management
Dysplasia or adenocarcinoma found on screening biopsy
Uncontrolled colonic bleeding
Disease present 7-10 years

79. IBD and Pregnancy
many issues to women in their childbearing years

80. IBD and Pregnancy
There are no increases in adverse outcomes with quiescent IBD
Active increases the risk for adverse outcomes
The majority of medications for IBD are safe in pregnancy

81. Patient with IBD can expect a healthy baby

82. Thank you!

83. Any other questions? 陈焰