Ulcerative Colitis
Endoscopy of Ulcerative Colitis with Pseudopolyps

Video Endoscopic Sequence 1 of 22.

Endoscopy of Ulcerative Colitis with Pseudopolyps

This 53 year-old female suffering of longstanding ulcerative colitis.

Pathophysiology

Ulcerative colitis involves only the mucosa; it is characterized by the formation of crypt abscesses and a coexisting depletion of goblet cell mucin. In severe cases, the submucosa may be involved; in some cases, the deeper muscular layers of the colonic wall is also affected.

Acute severe colitis may result in a fulminant colitis or toxic megacolon, which is characterized by a thin-walled, large, dilated colon that may eventually become perforated. Chronic disease is associated with pseudopolyp formation in about 15-20% of cases. Chronic and severe cases can be associated with areas of precancerous changes, such as carcinoma in situ or dysplasia.

Anatomically, the large majority of cases involve the rectum; some patients develop terminal ileitis caused by an incompetent ileocecal valve. In these cases, about 30 cm of the terminal ileum is usually affected.

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Endoscopic findings in ulcerative colitis

Video Endoscopic Sequence 2 of 22.

Endoscopic findings in ulcerative colitis. Endoscopy in UC typically reveals the following findings: Erythema Loss of the usual fine vascular pattern Granularity of the mucosa Friability Edema.

The granular appearance is manifested by changes in light reflection during colonoscopy. Instead of reflecting light in large patches, the granular mucosa reflects a multitude of small points of light, giving the appearance of "wet sandpaper"

In contrast to Crohn's disease, lower endoscopy in ulcerative colitis shows continuous and circumferential involvement, with no normal areas of mucosa.

 

 

Endoscopic View of Ulcerative Colitis with Pseudopolyps

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Endoscopic View of Ulcerative Colitis with Pseudopolyps

Long segment of the transverse colon with Pseudopolyps

They can range from a few millimeters in diameter to a centimeter or more. They tend to be taller than they are wide and can mimic neoplasms; biopsy confirms that they are not neoplastic . Pseudopolyps are associated with increased severity and more extensive involvement in UC. However, the outcome in patients with pseudopolyps is better than in those with similar disease extent and severity who do not have pseudopolyps.

 

Endoscopy of Ulcerative Colitis with Pseudopolyps

Video Endoscopic Sequence 4 of 22.

Endoscopy of Ulcerative Colitis with Pseudopolyps

An important role for colonoscopy is in the surveillance of longstanding extensive ulcerative colitis where there is an increased risk of developing carcinoma.
Show polyps made up primarily of granulation tissue. These when contiguous may fuse causing irregular masses.

Psychological and psychosocial stress factors can play a role in the presentation of ulcerative colitis and can precipitate exacerbations. Smoking is negatively associated with ulcerative colitis. This relationship is reversed in Crohn disease. Milk consumption may exacerbate the disease.

 

Ulcerative Colitis

Video Endoscopic Sequence 5 of 22.

Endoscopic Image of Ulcerative Colitis with Pseudopolyps

Inflammatory polyps (pseudopolyposis) Pseudopolyposis is a term hallowed by usage. It has, however, been suggested that there is nothing ‘pseudo’ about these polyps which should, more appropriately, be referred to as benign inflammatory polyps or regenerative polyps, depending on the histopathological appearances.

 

Ulcerative Colitis

Video Endoscopic Sequence 6 of 22.

Gradual transition to normal mucosa.

The extent of colitis usually remains constant from the onset with the length of colonic involvement defining the classification of ulcerative colitis: proctitis (limited to the rectum), proctosigmoiditis or left-sided colitis (extending up to the splenic flexure), or pancolitis/extensive colitis (extending into the transverse colon).

 

The appendicular area

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The appendicular area

A subset of patients with UC demonstrates focal inflammation around the appendiceal orifice not contiguous with disease elsewhere in the colon.

Ulcerative Colitis

Video Endoscopic Sequence 8 of 22.

A polyp in the ascending colon

The severity of ulcerative colitis can be graded as follows:

Mild - Bleeding per rectum and fewer than 4 bowel motions per day.

Moderate - Bleeding per rectum with more than 4 bowel motions per day.

Severe - Bleeding per rectum, more than 4 bowel motions per day, and a systemic illness with hypoalbuminemia (< 30 g/L).

 

 

Ulcerative Colitis

Video Endoscopic Sequence 9 of 22.

Indications for Endoscopy in Ulcerative Colitis

There are multiple indications for endoscopy in patients with ulcerative colitis, including initial diagnosis; differentiation from Crohn's disease, infectious, and other colitides; evaluation of extent of colonic involvement; determination of the activity and severity of disease; monitoring response to medical management; and surveillance for dysplasia and colorectal cancer.

 

Ulcerative Colitis

Video Endoscopic Sequence 10 of 22.

The Hepatic Flexure

Findings in UC begin at the anal verge and extend proximally. The involvement is contiguous and circumferential, with inflammation beginning from the point of origin and continuing to a gradual transition to normal mucosa.

 

Ulcerative Colitis

Video Endoscopic Sequence 11 of 22.

Endoscopic Appearance of Ulcerative Colitis with Pseudopolyps.

Biopsy or polypectomy of lesions greater than 1 cm in diameter or different in appearance or colour from their fellows is advisable to enable definition of polyp type and for exclusion of malignancy.

 

Ulcerative Colitis

Video Endoscopic Sequence 12 of 22.

Endoscopic Image of Ulcerative Colitis with Pseudopolyps

Endoscopy of pseudopolyps; these lesions are not specific to ulcerative colitis, although they are more common in this disorder than in Crohn's disease.

Random biopsies may reveal the changes of low grade or high grade dysplasia. The colonoscopist cannot usually distinguish flat dysplastic from normal mucosa, and the diagnosis therefore depends on the histopathological appearances. Dysplastic mucosa may however, be endoscopically visible as a DALM.

Video Endoscopic Sequence 13 of 22.

Random biopsies may reveal the changes of low grade or high grade dysplasia. The colonoscopist cannot usually distinguish flat dysplastic from normal mucosa, and the diagnosis therefore depends on the histopathological appearances. Dysplastic mucosa may however, be endoscopically visible as a DALM.

Ulcerative Colitis

Video Endoscopic Sequence 14 of 22.

Frequency

United States

In the Western world, ulcerative colitis has a prevalence of 3-10 cases per 100,000 population. Ulcerative colitis is 3 times more common than Crohn disease.

International

Geographically, ulcerative colitis is more common in the Western and Northern hemispheres; the incidence is low in Asia and the Far East.


Ulcerative Colitis

Video Endoscopic Sequence 15 of 22.

Endoscopic Image of Ulcerative Colitis with Pseudopolyps

Some biopsies are taken

Adenomatous polyps may occasionally be seen in patients with UC, though there is no etiological relationship.

 

 

 

 

Ulcerative Colitis

Video Endoscopic Sequence 16 of 22.

Ulcerative colitis may result in disease-related mortality. However, overall mortality is not increased in patients with ulcerative colitis, as compared with the general population. An increase in mortality may be observed among elderly patients with the disease. Mortality is also increased in patients who develop complications (eg, shock, malnutrition, anemia). Evidence suggests that mortality is increased in patients with ulcerative colitis who undergo any form of medical or surgical intervention.

 

 

 

 

 

Ulcerative Colitis

Video Endoscopic Sequence 17 of 22.

Race

Ulcerative colitis is more common in individuals living in temperate climates and in whites. There are sporadic increases in some Jewish populations. The disease is uncommon in the Far East.

Sex

Ulcerative colitis is slightly more common in men than in women.

 

Ulcerative Colitis

Video Endoscopic Sequence 18 of 22.

Age

Ulcerative colitis is uncommon in persons younger than 10 years. Most patients are 20-40 years of age at diagnosis. Another peak occurs at 60 years of age.

 

ulcerative colitis

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The diagnosis of ulcerative colitis is best made with endoscopy. Endoscopically, ulcerative colitis is characterized by abnormal erythematous mucosa, with or without ulceration, extending from the rectum to part or all of the colon. The inflammation is uniform, without intervening areas of normal mucosa, while skip lesions tend to characterize Crohn disease. Contact bleeding may also be observed, with mucus identified in the lumen of the bowel. Biopsy of the mucosa is recommended to identify the extent of the disease with respect to the thickness of the bowel wall.

Ulcerative Colitis

Video Endoscopic Sequence 20 of 22.

Histologically, most of the pathology is limited to the mucosa and submucosa. In fulminant cases, the muscularis propria can be affected. Pathologic features that are typically seen include intense infiltration of the mucosa and submucosa with neutrophils and crypt abscesses, lamina propria with lymphoid aggregates, plasma cells, mast cells and eosinophils, and shortening and branching of the crypts.
These features are not unique to ulcerative colitis. Except for crypt distortion, the same cellular response can be seen in acute infectious colitis or Crohn disease.

 

Ulcerative Colitis

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Ulcerative Colitis

Video Endoscopic Sequence 22 of 22.

Ulcerative Colitis
 

Video Endoscopic Sequence 1 of 7.

Endoscopy of Pancolitis. The entire colon is affected.

This is the case of a patient with long standing ulcerative colitis, male 37 year-old.

UC is marked by diffuse, superficial inflammation of the colonic mucosa, beginning in the rectum and extending proximally to involve any contiguous length of colon. The small intestine is not involved, except in the setting of extensive colitis, in which the most distal terminal ileum may exhibit similar superficial inflammation, termed backwash ileitis. Because the extent of colitis usually remains constant from the onset, the length of involved colon defines the classification of UC: proctitis (limited to the rectum), proctosigmoiditis or left-sided colitis (extending up to the splenic flexure), or pancolitis (extending into the transverse colon).

 

Ulcerative Colitis

Video Endoscopic Sequence 2 of 7.

A depressed ulcer is observed

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

 

Ulcerative Colitis

Video Endoscopic Sequence 3 of 7.

Extensive colitis (pancolitis). In pancolitis, inflammation extends into the transverse or right colon. Patients are more likely to present with diarrhea because of diminished absorptive capacity of the colon, accompanied by rectal bleeding and urgency. Abdominal cramps may be diffuse or localized, and patients are more likely to have weight loss, systemic or extraintestinal symptoms, and anemia.

 

Ulcerative Colitis

Video Endoscopic Sequence 4 of 7.

Endoscopy of Ulcerative Colitis

Clinical Severity

The severity of UC depends on both the length of colon involved and the severity of colonic inflammation.

In contrast to Crohn's disease, lower endoscopy in ulcerative colitis shows continuous and circumferential involvement, with no normal areas of mucosa.

 

Ulcerative Colitis

Video Endoscopic Sequence 5 of 7.

The cecum, the Ileocecal valve

Clinical Severity

Mild. In mild UC, patients have less than four bowel movements daily, with minimal cramps and urgency. Usually, most of the bowel movements occur early in the day; and after the morning evacuations, the patient is able to proceed with activities of daily life.

 

Ulcerative Colitis

Video Endoscopic Sequence 6 of 7.

The cecum.

Clinical Severity: Moderate. Patients with moderate UC havefour to eight bowel movements daily, more frequent rectal urgency, and postprandial cramping and bowel movements.Blood is present in most stools, and nocturnal wakening forbowel movements is common. The disease can interfere withdaily work or school activities and social life.

Severe. Patients with severe UC have more than eight bowelmovements daily, nocturnal bowel movements, severe urgencywith or without incontinence, and systemic signs that includelow -grade fever, night sweats, weakness, and weight loss.Abdominal tenderness, tachycardia, anemia, leukocytosis, andhypoalbuminemia are common.

Fulminant. Patients with fulminant colitis have more than 10bowel movements a day, nocturnal bowel movements, severeabdominal pain or relentless tenesmus, and rebound tendernessor distention with tympanic bowel sounds. They also haveprostration, high fever, and hypotension. Radiographic studiesshow evidence of mucosal edema, intramural air (pneumatosiscoli), colonic dilatation (toxic megacolon), or free abdominal air (perforation).

 

Ulcerative Colitis

Video Endoscopic Sequence 7 of 7.

Terminal Ileum: Backwash Ileitis

This video clip shows the cecum, the endoscope is advancing into the ileocecal valve to the terminal ileum which is completely normal.

Backwash Ileitis: Involvement of the distal ileum in ulcerative colitis (UC) is termed backwash ileitis (BWI). It generally is accepted as a distinct pathologic process in patients with UC.

 

Ulcerative colitis complicating pseudomembranous colitis

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Ulcerative colitis complicating pseudomembranous colitis of the right colon.

A 73-year-old man presented with chronic watery diarrhea and abdominal cramping of three months duration. Was under multiple antibiotics therapy prescribed from his general practitioner.

 

Ulcerative Colitis and superimposed pseudomembranous

Video Endoscopic Sequence 2 of 4.

This image and the video clip display a long segment of the descending colon with ulcerative colitis.

 

Ulcerative Colitis and superimposed pseudomembranous

Video Endoscopic Sequence 3 of 4.

Ulcerative Colitis and superimposed pseudomembranous colitis involving the right colon.

Colonoscopy revealed pseudomembranous colitis extending from the ascending colon to the cecum, and Clostridium Difficile, toxin was positive in the feces. The administration of vancomycin in addition to oral steroids resulted in rapid improvement of the condition.

 

Ulcerative Colitis with superimposed

Video Endoscopic Sequence 4 of 4.

Endoscopic Image of Ulcerative Colitis with superimposed pseudomembranous colitis.

Total colonoscopy is recommended for precise diagnosis when patients with ulcerative colitis develop intractable diarrhea during or after antibiotic therapy.

 

Ulcerative Colitis

Video Endoscopic Sequence 1 of 4.

Ulcerative colitis complicating Colon Cancer

Longstanding extensive UC is associated with a significantly increased risk of developing colon cancer. Colonoscopic surveillance is increasingly used in this group of patients.

Patients with ulcerative colitis have a 2 to 8 fold increased risk of developing colorectal cancer compared to the general population.

Colorectal cancer influences long term survival in patients with ulcerative colitis.

Stage of colorectal cancer at time of diagnosis is an important predictor of survival.

 

Ulcerative Colitis

Video Endoscopic Sequence 2 of 4.

This image shows a colonic cancer of the rectosigmoid junction.

Patients with ulcerative colitis and colorectal cancer have a stage distribution similar to patients with colorectal cancer without ulcerative colitis.

Survival of colorectal cancer is poorer for patients with ulcerative colitis than for patients with colorectal cancer without ulcerative colitis.

 

Ulcerative Colitis

Video Endoscopic Sequence 3 of 4.

Longstanding extensive UC is associated with a significantly increased risk of developing colon cancer. Colonoscopic surveillance is increasingly used in this group of patients.

It is well documented that there is an increased risk of developing cancer in ulcerative colitis when compared to the general population, although it is now thought that the risk is much lower than previously believed.

 

Ulcerative Colitis

Video Endoscopic Sequence 4 of 4.

In a patient with long-standing ulcerative colitis undergoing surveillance colonoscopy, the primary question is whether or not there is dysplasia present and not to make a diagnosis of inflammatory bowel disease.

 

Endoscopy of Ulcerative Colitis.

Video Endoscopic Sequence 1 of 5.

Endoscopy of Ulcerative Colitis.

Endoscopic findings in ulcerative colitis — Endoscopy in UC typically reveals the following findings:
Erythema
Loss of the usual fine vascular pattern
Granularity of the mucosa
Friability
Edema.

 

Endoscopic Image of Ulcerative Colitis.

Video Endoscopic Sequence 2 of 5.

This image and the video clips shows the typical serpinginous ulcers of ulcerative colitis after using indigo carmine stain.

Chromoendoscopy is characterized by intravital staining of colonic epithelium to enhance dysplastic mucosal changes, thereby allowing targeted biopsies of suspicious lesions. Indigo carmine is a contrast dye that has the ability to coat the colonic mucosa and allow identification of thedisruption of normal surface mucosal grooves. In comparison, methylene blue is an absorptive dye, which avidly stains normal mucosa, but is poorly absorbed by inflamed or dysplastic mucosa. The combination of chromoendoscopy and use of magnifying colonoscopes facilitates a thorough evaluation of mucosal details, which may not be discerned on routine colonoscopy.

 

Endoscopic Image of Ulcerative Coliti

Video Endoscopic Sequence 3 of 5.

High magnification of the ulcers.

In order to detect flat-type dysplastic and cancerous lesions associated with longstanding ulcerative colitis, it is important to understand the minute findings detected by magnifying colonoscopy in active and quiescent stage of ulcerative colitis. The severity of mucosal findings by magnifying colonoscopy could be categorized as follows: polypoid mucosal tag which has severe ulceration and hemorrhage; coral-reef-like appearance which has coarse or nodular mucosa with ulcerations; minute defect of epithelia which has minute or shallow depressions surrounded by edematous mucosa; small yellowish spots which has minute whitish or yellowish coats; villi-like appearance which has shaggy appearance like small intestinal villi; and regularly arranged crypt opening which has round shaped and regularly arranged crypt.

 

Endoscopy of Ulcerative Colitis

Video Endoscopic Sequence 4 of 5.

A focal area of ulcerative colitis is appreciated, showing redness and ulcerations.

A pit-pattern classification has been developed based upon the staining pattern, which allows endoscopic prediction of histopathologic findings with an accuracy of 93%: Type I and II staining patterns are consistent with nonneoplastic lesions, and types III through V predict neoplastic lesions. Chromoendoscopy can increase the yield of neoplastic lesions detected in ulcerative colitis by 3- to 4.5-fold as compared with conventional colonoscopy.

 

Endoscopy of Ulcerative Colitis

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A high magnification of a focal area of ulcerative colitis.

 

Endoscopy of Ulcerative Colitis

Video Endoscopic Sequence 1 of 3.

Endoscopy of Ulcerative Colitis.

There are several serpingenous ulcer´s. friability, exudation, and bleeding, with increasingly larger areas of ulcerations.

 

Endoscopy of Ulcerative Colitis.

Video Endoscopic Sequence 2 of 3.

More images of ulcerative colitis, with increasingly larger areas of ulcerations.

 

Endoscopy of Ulcerative Colitis.

Video Endoscopic Sequence 3 of 3.

Chromoendoscopy using methilene blue.

 

Case of severe ulcerative colitis.

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Case of severe ulcerative colitis.

 

 

 

 

 

 

Case of severe ulcerative colitis.

Video Endoscopic Sequence 2 of 6.

Ulcerative Colitis.

The recto-sigmoid junction.
Coarsely nodular deformity of mucosal contour in ulcerative colitis. The mucosa is erythematous and friable. Coarsely nodular deformity of mucosal contour in ulcerative colitis.

 

 

 

 

Case of severe ulcerative colitis.

Video Endoscopic Sequence 3 of 6.

Ulcerative Colitis.

Moderate to severe colitis is characterized by granularity, friability, exudate, spontaneous bleeding and increasingly larger areas of ulceration.
Pathophysiology: Ulcerative colitis is defined as continuous idiopathic inflammation of the colonic or rectal mucosa. The rectum is involved in more than 95% of cases. Some authorities believe that the rectum is always involved in an untreated patient. Partial healing may occur in a patient treated with topical therapy, creating diagnostic confusion.

 

Case of severe ulcerative colitis.

Video Endoscopic Sequence 4 of 6.

Ulcerative Colitis.

Necrosis, edema, exudate and friability are observed.
Causes:
An unknown factor causes an immune-mediated inflammatory response in the intestinal mucosa.
Genetic susceptibility (chromosomes 12 and 16) is a factorassociated with ulcerative colitis.
A positive family history (observed in 1 of 6 relatives) is associated with a higher risk for developing the disease.
Smoking is not associated with ulcerative colitis This relationship is reversed in Crohn disease. Environmental factors.
Dietary factors: Milk consumption may exacerbate the disease.
Appendectomies have a negative association with ulcerative colitis.

 

Case of severe ulcerative colitis.

Video Endoscopic Sequence 5 of 6.

Ulcerative Colitis.

Some biopsies are taken from irregular areas in order to rule out malignancy or dysplasia.


 

Ulcerative Colitis

Video Endoscopic Sequence 6 of 6.

Ulcerative Colitis.

Multiples pseudopolyposis are seen and the video clip displays hundreds of pseudopolyps.


 

 

Ulcerative Colitis

Video Endoscopic Sequence 1 of 3.

Ulcerative Colitis of long standing evolution.

On the image and the video clip are observed multiple pseudo polyps and scar areas of the ascending colon. There are pseudopolyps and chronic inflammation of colonic mucosa.

 

Ulcerative Colitis of long stand evolution.

Video Endoscopic Sequence 2 of 3.

Ulcerative Colitis

The video clip displays the cecum; a pseudo polyp is observed; some biopsies were taken.

 

Ulcerative Colitis of long stand evolution.

Video Endoscopic Sequence 3 of 3.

Ulcerative Colitis

The biopsy forceps is observed.

Ulcerative Colitis

Ulcerative Colitis.

There are several serpingenous ulcers with pseudo polyps, friability, exudate, and bleeding, with increasingly larger areas of ulcerations.

 

Ulcerative Colitis

Video Endoscopic Sequence 1 of 2.

Ulcerative Colitis.


A 65 year-old male presented with chronic diarrhea Rectal bleeding associated with the passage of mucus.

The image and the video clip displays a pancolitis. The mucosa is friable, erythematous, and edematous. This is uniform throughout the entire circumference of the colon.

 

Ulcerative Colitis.

Video Endoscopic Sequence 2 of 2.

Ulcerative Colitis.

 

Ulcerative Colitis.

Collagenous Colitis.

A 37 year-old female with diarrhea of 6 months. She was hospitalized in another institution, a barium enema performed and The Rx resulted negative; the entire colon was affected with segmental redness. Patients are usually middle-aged women (9:1 is the female-male ratio in collagenous colitis).

 

Severe Ulcerative Colitis

Video Endoscopic Sequence 1 of 25.

Case of Severe Ulcerative Colitis

The image and the video clips shows an atypical perianal fissure

This is a 52 year old male spanish, with longstanding ulcerative colitis. Four months previously he came to our endoscopic unit for the management of this disease. The first time he had a frequency of 10 to 20 mucosanguineous evacuations per day and severe edema of the legs with a 20 lbs weight loss. His general aspect was of a critacally ill patient.
Initially, he had had an excellent improvement of his clinical picture with the therapy with Infliximab. The patient regained over 20 pounds of his weight, but it was only during this period, because then he relapsed dramatically with exacerbation.of this disease. Despite of the treatment, again with weight loss of 20 lbs. The patient reappears the severe edema of the legs with tachycardia and elevation of the white blood cell count with 22.000 with 92% of neutrophils.

Due to sudden deterioration underwent surgery.

 

 

 

 

Case of Severe Ulcerative Colitis

Video Endoscopic Sequence 2 of 25.

Case of Severe Ulcerative Colitis

Findings on the comprehensive metabolic panel may include the following:

Hypoalbuminemia (ie, albumin < 3.5 g/dL)
Hypokalemia (ie, potassium < 3.5 mEq/L)
Hypomagnesemia (ie, magnesium < 1.5 mg/dL)
Elevated alkaline phosphatase: More than 125 U/L
suggests primary sclerosing cholangitis (usually >3 times
the upper limit of the reference range).

 

 

 

 

 

Severe Ulcerative Colitis

Video Endoscopic Sequence 3 of 25.

Grossly, the colonic mucosa appears hyperemic, with loss of the normal vascular pattern. The mucosa is granular and friable. Frequently, broad-based ulcerations cause islands of normal mucosa to appear polypoid, leading to the term pseudopolyp.

Ulcerative colitis is a chronic disease associated with diffuse mucosal inflammation of the colon, giving rise to significant morbidity and recurrent symptoms of intermittent bloody diarrhea, rectal urgency, and tenesmus. Onset of symptoms typically occurs between 15 and 40 years of age, with a second peak in incidence between 50 and 80 years of age. Men and women are equally likely to develop ulcerative colitis.

Severe Ulcerative Colitis

Video Endoscopic Sequence 4 of 25.

Pseudopolyps are observed

The bowel wall is thin or of normal thickness, but edema, the accumulation of fat, and hypertrophy of the muscle layer may give the impression of a thickened bowel wall. The disease is largely confined to the mucosa and, to a lesser extent, the submucosa. Muscle-layer and serosal involvement is very rare; such involvement is seen in patients with severe disease, particularly toxic dilatation, and reflects a secondary effect of the severe disease rather than primary ulcerative colitis pathogenesis.

 

Severe Ulcerative Colitis

Video Endoscopic Sequence 5 of 25.

Endoscopic image of Ulcerative Colitis with multiple ulcers and pseudopolyps.

Early disease manifests as hemorrhagic inflammation with loss of the normal vascular pattern; petechial hemorrhages; and bleeding. Edema is present, and large areas become denuded of mucosa. Undermining of the mucosa leads to the formation of crypt abscesses, which are the hallmark of the disease.

The diagnosis of ulcerative colitis is best made with endoscopy and mucosal biopsy for histopathology. Laboratory studies are helpful to exclude other diagnoses and assess the patient's nutritional status, but serologic markers can assist in the diagnosis of inflammatory bowel disease.

 

Severe Ulcerative Colitis

Video Endoscopic Sequence 6 of 25.

Ulcerative colitis is a lifelong illness that has a profound emotional and social impact on affected patients.

Treatment of Acute, Severe Disease

Acute, severe ulcerative colitis (ie, >6 bloody bowel movements/d, with one of the following: fever >38°C, hemoglobin level < 10.5 g/dL, heart rate >90 bpm, erythrocyte sedimentation rate >30 mm/h, or C-reactive protein level >30) requires hospitalization and treatment with intravenous high-dose corticosteroids (hydrocortisone 400 mg/d or methylprednisolone 60 mg/d). A meta-analysis supports the use of glucocorticosteroids in inducing remission in acute severe ulcerative colitis.

 


Severe Ulcerative Colitis

Video Endoscopic Sequence 7 of 25.

Involvement of the muscularis propria in the most severe cases can lead to damage to the nerve plexus, resulting in colonic dysmotility, dilation, and eventual infarction and gangrene, a condition termed toxic megacolon. This condition is characterized by a thin-walled, large, dilated colon that may eventually become perforated. Chronic disease is associated with pseudopolyp formation in about 15-20% of cases. Chronic and severe cases can be associated with areas of precancerous changes, such as carcinoma in situ or dysplasia.

 

 

 

 

 

Severe Ulcerative Colitis

Video Endoscopic Sequence 8 of 25.

Chronic ulcerative colitis is associated with an increase in the risk of carcinoma, and a colonic carcinoma may easily be missed in the setting of ulcerative colitis. Patients with ulcerative colitis must be made aware of the significant risk of colon cancer, and surgical intervention in nonacute cases should be encouraged after 10 years of disease or when symptoms are refractory or steroid dependent. Indications for surgery in ulcerative colitis vary and are discussed in detail in Surgical Treatment.

As yet, no evidence suggests that regular endoscopic screening of patients with ulcerative colitis improves survival. However, the current standard of practice by many gastroenterologists is to continue screening these patients at some interval, owing to the risk of cancer development and possible legal implications if it is not detected.

 

 

 

 

Severe Ulcerative Colitis

Video Endoscopic Sequence 9 of 25.

Patients with severe disease can have signs of volume depletion and toxicity, including the following:

Fever
Tachycardia
Significant abdominal tenderness
Weight loss

 

 

 

 

Severe Ulcerative Colitis

Video Endoscopic Sequence 10 of 25.

The most common cause of death of patients with ulcerative colitis is toxic megacolon. Colonic adenocarcinoma develops in 3-5% of patients with ulcerative colitis, and the risk increases as the duration of disease increases. The risk of colonic malignancy is higher in cases of pancolitis and in cases in which onset of the disease occurs before the age of 15 years. Benign stricture rarely causes intestinal obstruction.

 

 

 

 

Macroscope Apperance of Ulcerative Colitis

Video Endoscopic Sequence 11 of 25.

The surgical specimen is observed

Historically, surgery has been viewed as definitive therapy for ulcerative colitis. Total proctocolectomy is often curative, alleviating symptoms and removing the risk of colonic adenocarcinoma. Prior to 1980, total proctocolectomy with end ileostomy or continent (or Koch) ileostomy was the mainstay of therapy.

To enlarge the image press on it.

 

Macroscope Apperance of Ulcerative Colitis

Video Endoscopic Sequence 12 of 25.

Historically, surgery has been viewed as definitive therapy for ulcerative colitis. Total proctocolectomy is often curative, alleviating symptoms and removing the risk of colonic adenocarcinoma. Prior to 1980, total proctocolectomy with end ileostomy or continent (or Koch) ileostomy was the mainstay of therapy.

Indications for urgent surgery in patients with ulcerative colitis include the following:

Toxic megacolon refractory to medical management
Fulminant attack refractory to medical management
Uncontrolled colonic bleeding
Perforation (free or walled off)
Obstruction and stricture with suspicion for cancer.

Indications for elective surgery in ulcerative colitis include the following:

Refractory disease with failure of medical management
Chronic steroid dependency
Dysplasia or adenocarcinoma found on screening biopsy
Disease present 7-10 years
Systemic complications from medications, particularly
steroids.
Failure to thrive, in children.

 

Abdomen MRI of our patient

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Abdomen MRI of our patient

Advances in MR technology have improved the quality of abdominal MRI and hence the ability to assess intestinal diseases. Rapid acquisition sequences have reduced the incidence of motion artifacts from intestinal peristalsis, while the use of phased-array coils has increased spatial resolution. Several intestinal contrast agents have undergone extensive trials. Meanwhile, the use of sequences that modulate MRI signal selectively, for example by suppressing fat tissue signal, can improve gadolinium-related enhancement on T1-weighted images, as well as boosting T2 signal in pathologic tissues.

These improvements-together with the intrinsic capability of multiplanar acquisition, the use of different imaging parameters, inherently high soft-tissue contrast, and the lack of ionizing radiation-make MRI a useful, effective tool for evaluating the normal bowel and detecting intestinal wall changes indicative of neoplastic and inflammatory bowel diseases.

To enlarge the image press on it.

 

Abdomen MRI of our patient

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Colonic wall thickening is usually less extensive in ulcerative colitis than in Crohn's disease. CT studies have shown the mean value of wall thickening to be 7 mm vs. 13 mm, respectively.10-14 The thickening can be visualized easily on either T1- or T2-weighted MR sequences, preferably on axial images.

Marked thickening of the rectal or colonic wall exceeding 10 mm can be observed in ulcerative colitis as well in severe phases of activity. The wall's inner profile can show a waved configuration in both ulcerative colitis and Crohn's disease. The outer wall profile is sharper and smoother in ulcerative colitis, due to the intramural rather than transmural extent of inflammation.

 

Abdomen MRI of our patient

Video Endoscopic Sequence 15 of 25.

Cross-sectional imaging studies such as CT, MRI, and US are useful for showing the effects of these conditions on the wall of the bowel and for demonstrating intra-abdominal abscesses and other extraluminal findings in patients with more advanced disease. Thus, barium studies and cross-sectional imaging studies have complementary roles in the evaluation of ulcerative colitis.


 

Pyoderma Gangrenosum

Video Endoscopic Sequence 16 of 25.

Pyoderma Gangrenosum

This an extra intestinal manifestation of ulcerative colitis.

There is a foot abscess that appear with the exacerbation.

Extracolonic manifestations

Ulcerative colitis is associated with various extracolonic manifestations. These include uveitis, pyoderma gangrenosum, pleuritis, erythema nodosum, ankylosing spondylitis, and spondyloarthropathies. Reportedly, 6.2% of patients with inflammatory bowel disease have a major extraintestinal manifestation. Uveitis is the most common, with an incidence of 3.8%, followed by primary sclerosing cholangitis at 3%, ankylosing spondylitis at 2.7%, erythema nodosum at 1.9%, and pyoderma gangrenosum at 1.2%.However, reports vary, and some have stated that the incidence of ankylosing spondylitis is as high as 10%. Arthropathies occur in as many as 39% of patients with inflammatory bowel disease. About 30% of such patients have inflammatory back pain, 10% have synovitis, and as many as 40% have radiologic findings of sacroiliitis.

 

There is a foot abscess that appear with the exacerbation.

Video Endoscopic Sequence 17 of 25.

Another image of the foot abscess.

 

subcutaneous abscess

Video Endoscopic Sequence 18 of 25.

An subcutaneous abscess near to the clavicular notch that appear with the exacerbation of the disease.

The association of pyoderma gangrenosum or erythema nodosum with UC is well known. In addition, pustular eruption has been reported in UC. Our patient with UC who exhibited subcutaneous abscesses, as well as pustular eruption with a clinical course paralleling that of UC exacerbation.

Anecdotal reports of recurrent subcutaneous abscesses unrelated to pyoderma gangrenosum exist, and multiple sclerosis also has been weakly associated with ulcerative colitis.

 

The subcutaneous abscess was drainage

Video Endoscopic Sequence 19 of 25.

The subcutaneous abscess was drainage

Extraintestinal complications affect 25-30% of patients
with ulcerative colitis. These extraintestinal disorders
significantly contribute to morbidity and mortality of
ulcerative colitis patients. While some disorders parallel
the activity of the colitis, other abnormalities run a clinical
course independent of the bowel disease. The pathogenesis
of these disorders is unknown, but the variable
relationships to the severity of colitis and the variable
responses to a proctocolectomy suggest considerable
heterogeneity.

 

The subcutaneous abscess was drainage on his foot.

Video Endoscopic Sequence 20 of 25.

The subcutaneous abscess was drainage on his foot.

 

Ulcerative Colitis

Video Endoscopic Sequence 21 of 25.

Ulcerative Colitis

Video Endoscopic Sequence 22 of 25.

Ulcerative Colitis

Video Endoscopic Sequence 23 of 25.

Ulcerative Colitis

Video Endoscopic Sequence 24 of 25.

Ulcerative Colitis

Video Endoscopic Sequence 25 of 25.

Appendiceal involvement in ulcerative colitis

Video Endoscopic Sequence 1 of 3.

Endoscopy of Ulcerative Colitis of the Appendix

This a 29 year-old male, who has been suffering from ulcerative colitis during three years, had been previously treated at another clinic, we practiced a total colonoscopy, finding typical picture of ulcerative colitis, which has infiltrated the rectum and sigmoid colon, starting some lesion in the descending colon, the rest of the colon was unremarkable, except for the cecum wich has around the hole of the appendix some lesions of ulcerative colitis, the observed hole Appendix achieving wide view multiple lesions infiltrate the lumen of the appendix.

Determination of the clinical significance of skip lesions in the appendix will contribute to elucidation of the pathogenesis of ulcerative colitis.

Although the human appendix is considered a vestigial remnant, many case-control studies suggest that previous appendectomy is rare in UC patients. Patients with previous appendectomy have a delayed onset of UC, a reduced need for immunomodulators and proctocolectomy, and a reduced relapse rate and extent of UC. Moreover, several investigators reported the improvement of UC after appendectomy, especially in young patients with ulcerative appendicitis. Because, disclosed that the number of early-but-not-mature-activated T cells is significantly increased in the appendix of UC patients, That suspects that the appendix may be a priming site in the occurrence of UC.

Determination of the clinical significance of skip lesions in the appendix will contribute to elucidation of the pathogenesis of ulcerative colitis.

The role of the appendix as an immunomodulator

It could be the key to the the cure of ulcerative colitis?



 

Appendiceal involvement in ulcerative colitis

Video Endoscopic Sequence 2 of 3.

Appendiceal involvement in ulcerative colitis

Patients with ulcerative appendicitis experience a more aggressive and relapsing disease course compared with those without ulcerative appendicitis. Whereas UC patients with long-standing disease and pancolitis have an increased risk of colorectal cancer occurrence. the inflamed appendiceal orifice in patients with ulcerative appendicitis may block excretion from the cavity, resulting in the occurrence of appendiceal mucocele and/or adenocarcinoma. Therefore recommend total colonoscopy for early detection of appendiceal inflammation and/or neoplasms, even in patients with distal UC.

El Salvador Atlas of Gastrointestinal Video Endoscopy

 

Appendiceal involvement in ulcerative colitis

Video Endoscopic Sequence 3 of 3.

Endoscopic View of Ulcerative Colitis and apendiceal involment

 

Naganuma M, Iizuka B, Torii A, Ogihara T, Kawamura Y, Ichinose M, et al. Appendectomy protects against the development of ulcerative colitis and reduces its recurrence: results of a multicenter case-controlled study in Japan. Am J Gastroenterol. 2002;96:1123-6.

Matsumoto T, Nakamura S, Shimizu M, Iida M. Significance of appendiceal involvement in patients with ulcerative colitis. Gastrointest Endosc. 2002;55:180-5. 

Scott IS, Sheaff M, Coumbe A, Feakins RM, Rampton DS. Appendiceal inflammation in ulcerative colitis. Histopathology. 1998;33:168-73. 
Medline

Cohen T, Pfeffer R, Valensi Q. «Ulcerative appendicitis» occurring as a skip lesion in chronic ulcerative colitis. Am J Gastroenterol. 1974;62;151-5. 


 

Scars Ulcerative colitis

Video Endoscopic Sequence 1 of 3.

Endoscopy scars of inflammatory bowel disease

A 33-year-old, 5 year previously had been diagnosed with ulcerative colitis. He was treated from its beginning with three months of cyclosporine and mesalamine, with clinical remission of the symptomatology.

In this image as well as the video clip, displays the descending colon with multiple scars and vascularization.

 

 



 

scars of inflammatory bowel disease

Video Endoscopic Sequence 2 of 3.

Endoscopy of scars of inflammatory bowel disease. Descending colon.

 

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scars of inflammatory bowel disease

Video Endoscopic Sequence 3 of 3.

Retroflexed image inside of the ascending colon observing multiple scars.

 

 

 

 

 


 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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