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Chapter 4: Inflammatory bowel disease 169

can be tried. Urgency and diarrhoea can be treated 2 Genetic: HLA B27 is more common in patients.
with loperamide or codeine, whereas constipation can 3 Smoking: Patients presenting with ulcerative coli-
be helped by increased soluble fibre intake. tis are more likely to be non-smokers or recent ex-
smokers.
4 Immunological: pANCA may be found in ulcerative
Ulcerative colitis
colitis.
Definition
Chronic inflammatory bowel disease affecting only the Pathophysiology
large bowel, characterised by the formation of crypt ab- Ulcerative colitis is characterised by continuous inflam-
scesses (see Table 4.4). mation starting in the rectum (proctitis) and extending
variably to the descending colon or there may be a total
Incidence colitis (pancolitis). In a few patients inflammation of the
5per 100,000 per year. distal terminal ileum occurs termed backwash ileitis.

Age Clinical features
Peak in young adult life. The condition is characterised by acute exacerbations
interspersed by clinical remission. In acute episodes, pa-
Sex tients present with diarrhoea containing blood and mu-
F > M cous which may be copious and associated with urgency.
There may be extra-gastrointestinal features including
Aetiology erythema nodosum and pyoderma gangrenosum in the
Multifactorial aetiology including skin, iritis, arthropathy of large joints, sacroiliitis and
1 Familial: Familial tendency, some concordance be- ankylosing spondylitis (HLA B27) and chronic liver dis-
tween monozygotic twins. ease.

Table 4.4 Inflammatory bowel disease

Criterion Ulcerative colitis Crohn’s disease
Extent Large bowel only May involve entire gastrointestinal tract
Rectal involvement Almost invariable Variable
Disease continuity Continuous Discontinuous
Depth of inflammation Mucosal Transmural
Mucosal appearance Multiple small ulcers Cobblestone, discrete deep ulcers and fissures
Pseudopolyps
Histological features Crypt abscesses Transmural inflammation
No granulomas Granulomas (50%)
Presence of anal lesions 25% of cases 75% of cases with large bowel disease
25% of cases with small bowel disease
Frequency of fistula Uncommon 10–20% of cases
Risk of developing cancer Significant Rare
Medical management Topical agents, then oral or systemic 5-ASA drugs +/− steroids to induce remission
treatment. 5-ASA drugs +/− steroids and for maintenance. Oral agents often
used to induce remission. Steroids not required due to multifocal disease.
used in maintenance.
Surgical management Pan proctocolectomy is performed in 90% of patients require surgery at some time.
patients with complications, failure to Surgery is non curative and thus only
thrive, or as prophylaxis against symptomatic bowel is resected with the aim of
carcinoma. maintaining continuity