Video Endoscopic Sequence 1 of 110.

This is the case of 50 year-old female, three years previous was diagnosed as having ulcerative colitis in another country. The clinical course began with severe constipation during 6 month following with bloody loose bowel movements.

Now presented with frequent episodes of rectal bleeding with mucus, diarrhea, rectal pain, urgency, tenesmus, intermitent severe abdominal pain referred to left flank, and pitting edema of the both leg, Hb 10.8 gr/dl. hypoalbuminemia, elevated platelet count, extreme fatigue, patient looks pale and weight loss of 30 libs.

CT scan shows ingorged splenic angle and descending colon with ascites. Pacient is admitted for stabilization.

Because of the severity of the clinical picture and the severity and extention of the pancolitis, surgery was initially suggested as a treatment option, but patient instead chose medical management, which included prednisone 50 mg PO daily for 10 days, gradually diminishing doses by 10 mg/day every 10 days, plus sulfidine 2 tablets PO after every meal. Corticosteroids should be used to treat active ulcerative colitis. They have no role in maintenance treatment to prevent relapse. The dosage and routes of administration vary with the severity and location of ulcerative colitis.

After 10 days of treatment and 18 after the colonoscopy, the patient is readmitted to the hospital because of increased abdominal pain and sepsis. WB counts: 21,900 with 98% neutrophils, with a hemoglobin of 10 g/dl. Next day, patient presents with hypotension, tachycardia and signs of tissue hypoperfusion those sign are consistent of toxic megacolon.

The patient underwent emergency surgery
(Colectomy with ileostomy).

All endoscopic images of this atlas download a video clip.

Video Endoscopic Sequence 2 of 110.

A full colonoscopy was performed. There are multiple
rectal ulcers. 

The are multiple deep ulcers and loss of normal vascular
pattern in the rectal area that have to disclose Crohn
disease or Cytomegalovirus Colitis.

Video Endoscopic Sequence 3 of 110.

The image and the video clips show a deep rectal ulcer.

Endoscopic images show multiple ulcerations in the rectal
area, with the first ulcer immediate to the pectinate line,
with a more severe pattern of ulceration above the
rectosigmoid juction.

Video Endoscopic Sequence 4 of 110.

The recto-sigmoid juction

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

Video Endoscopic Sequence 5 of 110.

Close up of deep and large ulcer in the rectum

Severe ulcerative colitis, the least common form of the
disease, occurs in 15% of all patients with ulcerative colitis.
This form of the disease may be the initial presentation or
may represent a progression from a less severe attack.
Diarrhea is profuse and rectal bleeding is constant and
severe. Fever is marked and sustained, and appetite and
weight are both severely diminished. Abdominal cramps
are severe and tenderness may be localized, indicating
impending perforation. Leukocytes greater than 10,000,
severe anemia, and hypoalbuminemia resulting from low
protein intake (anorexia) and increased chronic loss of
albumin are hallmarks of this form of the disease.

Medical therapy is often ineffective for this type of
patient, and colectomy is often required.

Video Endoscopic Sequence 6 of 110.

Multiple biopsies across the colon was acquired.

Hospitalization

Hospitalization is indicated for the following reasons: 1. Failure of mild disease to improve significantly within four weeks of the start of outpatient treatment. Hospitalization removes the patient from an aggravating environment and provides the physician with the opportunity to initiate more effective and intensive therapeutic measures. 2. Severe illness with anorexia, nausea, vomiting, fever and uncontrollable bloody diarrhea (severe ulcerative colitis). Early hospitalization is critical for such patients so that they may be provided with therapy to control the disease and prevent complications, especially toxic megacolon. 3. Development of local or systemic complications including massive hemorrhage, persistent anemia, severe hypoalbuminemia, and/or cancer. Hospitalization at this time provides for assessment of the need for surgical therapy.

Video Endoscopic Sequence 7 of 110.

Mesalamine (5-aminosalicylic acid mesalazine, or
5-ASA) has been shown to be the active part of
sulfasalazine and is effective in the treatment of active
disease and in maintenance therapy to prevent relapse.

Video Endoscopic Sequence 8 of 110.

Mucosal biopsies are useful both for confirming the
diagnosis and for accurately defining the extent of
ulcerative colitis, which can be underestimated on the basis
of endoscopic appearance alone. In addition to its role in
the initial evaluation of IBD, endoscopy is an effective
tool in the reevaluation of patients with indeterminate
colitis. According to a prospective population-based study,
33% of patients with indeterminate colitis could be
reclassified as ulcerative colitis after 1-2 years of follow-up.

Video Endoscopic Sequence 9 of 110.

Splecnic Angle

Colonoscopy with ileoscopy is the preferred endoscopic
procedure in the initial evaluation of patients with
suspected inflammatory bowel disease (IBD).
Colonoscopy allows for direct mucosal visualization and
biopsies, thereby facilitating the diagnosis and
determination of colonic extent, activity, and severity of
ulcerative colitis.

Video Endoscopic Sequence 10 of 110.

Endoscopy of Severe Ulcerative Colitis

Severe colitis noted during colonoscopy. The mucosa is
grossly denuded and multiple pseudopolyps.

Extensive colitis (pancolitis) is diagnosed when
inflammation extends into the transverse or right colon.
In this setting patients are more likely to present with
diarrhea as a result of the diminished absorptive capacity
of the colon, accompanied by rectal bleeding, urgency and
tenesmus. Cramping abdominal pain may be diffuse or
localized, and patients are more likely to have weight loss,
systemic or extraintestinal symptoms, and anemia.

Video Endoscopic Sequence 11 of 110.

The image shows confluent superficial ulceration, and loss
of mucosal architecture.

The clinical severity of ulcerative colitis depends on both
the length of colon involved and the severity of colonic
inflammation.

Severe ulcerative colitis is manifest by more than eight
bowel movements daily, nocturnal bowel movements,
severe urgency with or without incontinence, and systemic
signs including low-grade fever, night sweats, weakness,
and weight loss. Abdominal tenderness, tachycardia,
anemia, leukocytosis, and hypoalbuminemia are common.

Video Endoscopic Sequence 12 of 110.

Colonoscopy of Severe Ulcerative Colitis

Advanced and severe active disease. When ulcerative
colitis is moreadvanced and severe, the inflamed mucosa is
often covered with purulent exudate.

Video Endoscopic Sequence 13 of 110.

Extensive Pseudopolyposis

There may be considerable overlap between the
endoscopic findings in ulcerative colitis and other colitides
such as infectious, ischemic, and radiation colitis.
Endoscopic features common to these disorders include
erythema, edema, and granularity of the colonic mucosa.
The use of nonsteroidal anti-inflammatory drugs
(NSAIDs), sodium phosphate-based bowel preparations,
hydrogen peroxide, and glutaraldehyde solutions used for
scope disinfection can induce colonic mucosal changes,
resembling IBD.

Video Endoscopic Sequence 14 of 110.

Twenty to 25% of patients with extensive ulcerative colitis eventually undergo colectomy, usually because their disease has not responded to medical therapy. The decision between surgery and continued medical therapy is often not clear-cut, and in many cases arguments can be made for either course. In ulcerative colitis, colectomy is a “curative” procedure, in contrast to Crohn’s disease, in which there is a significant likelihood of recurrence some time after the colectomy. The development of the ileoanal anastomosis, eliminating the need for an ileostomy, has made the thought of colectomy more tolerable for many. In general, patients who require continuous high-dose cortico-steroids and/or immunosuppressants to keep their disease under control should be strongly advised to consider colectomy.Those at high risk for colonic carcinoma (pancolitis of greater than 10 to 15 years duration) should also be considering colectomy or alternatively entry into a colonoscopic surveillance program.

Video Endoscopic Sequence 15 of 110.

Patients with ulcerative colitis are susceptible to
superimposed bacterial or viral colitis, and furthermore,
one third of patients with suspected IBD may in fact have
an underlying infectious etiology for their colitis. Rectal
biopsies showing histopathologic findings of a chronic
inflammatory infiltrate, basal lymphoid aggregates, and
architectural distortion may be useful in differentiating
IBD from self-limited colitis with a probability of up to 80%.

Video Endoscopic Sequence 16 of 110.

The mucosa of the ascending colon appers normal

Complete colonoscopy into the cecum and terminal ileum
is most helpful in distinguishing ulcerative colitis from
Crohn’s disease.

Ulcerative colitis is characterized by diffuse, superficial
inflammation of the colonic mucosa that begins in the
rectum and extends proximally to involve any contiguous
length of colon. The small bowel is not involved, although
the distal ileum may exhibit similar superficial
inflammation, usually in the setting of extensive colitis,
termed backwash ileitis.

Video Endoscopic Sequence 17 of 110.

The Cecum

Is it important to observe this colonoscopy taken 18 days
before the surgery, in that date in the coloscopy the cecum
and ascending colon appeared of normal appearance,
nevertheless the inflammatory activity of this disease has
been quite severe and progressive in spite of medical
treatment. See the video clips of the surgical specimen.

Video Endoscopic Sequence 18 of 110.

Hepatic angle: gradual transition to normal mucosa.

At the time of the colonoscopy the inflamatory activity was
to the transverse colon almost limiting to the hepatic angle,
nevertheless the inflamatory activity was progresive that
18 days after, the surgical specimen shows multiple ulcers
and pseudopolyposis in the ascending colon and cecum.

Video Endoscopic Sequence 19 of 110.

Endoscopic View of Severe Ulcerative Colitis

Inflammatory pseudopolyps may be seen in patients with
severe ulcerative colitis, and occur due to inflamed and
regenerating mucosa surrounded by ulcerations, resulting
in a cobblestone appearance at endoscopy. Pseudopolyps
do not regress with treatment and tend to persist even in
the presence of quiescent disease. They cannot be
distinguished from neoplastic polyps on the basis of
endoscopic appearance alone, and therefore
histopathologic examination of polyps that display atypical
features may be necessary to exclude dysplasia and/or
malignancy.

Video Endoscopic Sequence 20 of 110.

Endoscopic Image of Severe Ulcerative Colitis

Acute severe ulcerative colitis is a medical emergency.
Recognition of severe ulcerative colitis is based on a
comprehensive clinical assessment. The Truelove and
Witts criteria still remain useful in characterizing the
severity of this condition.

Video Endoscopic Sequence 21 of 110.

Colonoscopy of Severe Ulcerative Colitis

Pseudopolyposis is a frequent sequela of ulcerative colitis
(UC), pseudopolyposis may grow to a very large size,
producing a mass-like appearance called localized giant
pseudopolyposis or inflammatory polyposis of the colon.
This rare lesion mimics villous adenoma or carcinoma on
barium enema and conventional endoscopy.

Video Endoscopic Sequence 22 of 110.

Extensive Ulceration with Pseudopolyposis

Video Endoscopic Sequence 23 of 110.

Pseudopolyps are knobby, bulging areas of mucosa
resulting from necrosis. They occur as multiple polyps and
can be several centimeters long. They often have a soft,
whitish surface, though sometimes they can be tinged with
blood. Pseudopolyps can also occur as bridging folds.

Video Endoscopic Sequence 24 of 110.

Endoscopic Appearance of Severe Ulcerative Colitis

Localized giant pseudopolyposis is seen in both UC and
Crohn’s disease. Pseudopolyps are formed by ulceration,
which undermines the muscularis mucosae and creates
mucosal tags that remain as polyps after regeneration.
Localized giant pseudopolyposis is considered to result
from enlarged mucosal tags that become elongated by the
tractive force of peristalsis and the fecal stream.

Video Endoscopic Sequence 25 of 110.

Rectal ulcers, the colonoscope has returned to the rectum.

Video Endoscopic Sequence 26 of 110.

Multiple Rectal Ulcers.

Video Endoscopic Sequence 27 of 110.

The histological features of ulcerative colitis parallel the
endoscopic appearance of a diffuse, continuous pattern of
superficial inflammation within the involved mucosal
segments and normal proximal mucosa. The principle
components are disruption of glandular architecture and
an inflammatory infiltrate. While there are no
pathognomonic histological criteria for the diagnosis of
ulcerative colitis.

Video Endoscopic Sequence 28 of 110.

Endoscopic biopsies are crucial in the initial evaluation of
ulcerative colitis, to accurately exclude self-limited colitis,
and to differentiate ulcerative colitis from Crohn's disease.
Histologic findings in early stages of ulcerative colitis are
characterized by mucosal infiltration by acute inflammatory
cells, including neutrophils, lymphocytes, plasma cells, and
macrophages. Neutrophilic infiltration of crypts leads to
cryptitis and crypt abscesses. Due to the nonspecific
inflammatory findings, it may be difficult to distinguish
ulcerative colitis from acute colitis at this stage.

Video Endoscopic Sequence 29 of 110.

A primary distinction between chronic inflammatory bowel
disease such as ulcerative colitis and acute self-limited
(infectious) colitis is architectural distortion. In ulcerative
colitis, the normal vertical (“test-tube”) alignment of glands
is distorted and, often branched or irregularly shaped. The
glands are separated by expanded lamina propria
lymphocytes, plasma cells, and eosinophils, as well as by
neutrophils, which are normally sparse. The neutrophilic
infiltrate is localized to the base of the glandular crypts
and invades the crypts, producing crypt abscesses. In more
severe disease, the epithelial lining is destroyed, with
denuding ulcerations over the lamina propria.

Video Endoscopic Sequence 30 of 110.

Our patient presents edema of lower extremities clinical
sign which be considered in all patient with ulcerative
colitis as a serious stage. (Severe ulcerative colitis).

Our patient presents

Edema of lower extremities clinical sign that should be considered in every patient with ulcerative colitis as severe

There was hipoalbuminemia and scarce ascitis to the moment of the first hospitalization.

Video Endoscopic Sequence 31 of 110.

Pitting Edema

Severe ulcerative colitis: hypoalbuminemia resulting from
low protein intake (anorexia) and increased chronic loss of
albumin are hallmarks of this form of the disease.

Video Endoscopic Sequence 32 of 110.

Computed Tomography Scout View

Panoramic view in the first hospitalization that was taken
in the second day which is observed clearly marked that
the walls of the colon are thick.

In the first abdominal CT scan a thickening of the
descending colon, just belowthe splenic flexure, was seen,
with the question of malignancy.

Click on the Rx image to enlarge.

Video Endoscopic Sequence 33 of 110.

Computed Tomography Scout View

Computed tomography scout view is a mode of operating a
CT system. It is generally used to prescribe CT slices and
to display slice locations rather than for direct diagnosis.
However, a careful study of CT scout view can contribute
significantly to the diagnosis.

Click on the Rx. Image to enlarge.

Video Endoscopic Sequence 34 of 110.

Second Hospitalization

After 10 days of ambulatory treatment and 18 after the colonoscopy, the patient is readmitted to the hospital because of increased abdominal pain and sepsis. WB counts: 21,900 with 98% neutrophils, with a hemoglobin of 10 g/dl. The second day, patient presents with hypotension, tachycardia and signs of tissue hypoperfusion those sign are consistent of toxic megacolon .

The patient underwent emergency surgery
(Colectomy with ileostomy). 

Cyanosis of the extremities

Clinically, the patient with toxic megacolon presents as severely ill with a fever, tachycardia, dehydration, abdominal pain and distention). Examination reveals absent bowel sounds, tympany and rebound tenderness. Leukocytosis (greater than 10,000), anemia and hypoalbuminemia are often present. A plain x-ray of the abdomen will reveal dilation of a colonic segment or of the entire colon. On plain supine x-ray, dilation of the transverse colon is most often seen. This distention of the transverse colon does not indicate severity of disease in this segment of the colon; rather, the distention is determined by the anterior position of the transverse colon. Repositioning the patient to a prone position will redistribute the gas to the more posterior descending colon and will dramatically decrease gaseous tension in the transverse colon.

Secuencia Video Endoscópica 35 de 110.

Distal cyanosis

Severe attack with failure of medical treatment.

From the admitions prepare for colectomy in the second hospital day.

Surgery is used in cases of megacolon, risk of cancer, medical treatment failure, chronic cases and complications).

From the admition is prepared for colectomy in the second hospital day .

Video Endoscopic Sequence 35 of 110.

The patient's clinical condition deteriorated over the next
18 hours despite steroid and antibiotic therapy, and the
patient had to undergo total colectomy and ileostomy.

The diagnosis of toxic megacolon is based on clinical
findings, simple laboratory results, and a careful scrutiny of
the plain abdominal radiograph. Usually, no other radiologic investigations are required. Once toxic megacolon is diagnosed, the patient must be immediately admitted to an intensive care unit where he or she can be monitored by intensivists and a team of physicians and surgeons. The mortality rate is high, at 20%.

Video Endoscopic Sequence 36 of 110.

Plain Abdominal Rx

DIAGNOSIS — The diagnosis of toxic megacolon should
be considered in all patients presenting with abdominal
distension and acute or chronic diarrhea. The diagnosis is
clinical, based upon the finding of an enlarged dilated colon
accompanied by severe systemic toxicity. The initial
evaluation should be aimed at establishing the dia nosis of
toxic megacolon and at determining the underlyingetiology
to help institute specific therapeutic measures.

Video Endoscopic Sequence 37 of 110.

Toxic megacolon is defined as a severe episode of colitis
with segmental or total dilatation of the colon. It is typically
a complication of ulcerative colitis, but it may be a
complication of Crohn disease, antibiotic-related
pseudomembranous colitis, and other colitides.
Pathologically, acute fulminant colitis is associated with
neuromuscular degeneration and a rapid and extensive
colonic dilatation.

Video Endoscopic Sequence 38 of 110.

Computed Tomography Scout View in the second day of the second hospitalization

Toxic megacolon is a potentially lethal complication of inflammatory bowel disease (IBD) or infectious colitis that is characterized by total or segmental nonobstructive colonic dilatation plus systemic toxicity.

Toxic megacolon is characterized by an acute dilation of all or part of the colon to a diameter greater than 6 cm. (measured in the mid-transverse colon) and is associated with severe systemic toxicity. Toxic megacolon occurs in 1– 2% of patients with ulcerative colitis. Histological examination reveals extensive deep ulcerations and acute inflammation that involves all muscle layers of the colon and often extends to the serosa. This widespread inflammation accounts for toxic megacolon’s systemic toxicity (fever, tachycardia, localized abdominal pain and leukocytosis). The loss of colonic muscular tone results in the dilation of the colon.

Click on the image to enlarge

Video Endoscopic Sequence 39 of 110.

CT is valuable for the detection and characterization of
ulcerative colitis. CT typically demonstrates
circumferential, symmetrical wall thickening with fold
enlargement. Thickening of the colon wall (mean, 7.8 mm;
standard deviation, 1.9) may be present, with
inhomogeneous attenuation, a target appearance of the
rectum, and the proliferation of perirectal fat. The normal
colonic wall has a maximal thickness of 3 mm with the
lumen distended and 5 mm with the lumen collapsed. In
comparison, Crohn colitis causes greater bowel wall
thickening (mean, 11 mm; standard deviation, 5.1). Such
thickening appears in association with homogeneous
attenuation, fistula and abscess formation, and mesenteric
abnormalities.

Click on the image to enlarge

Video Endoscopic Sequence 40 of 110.

Patients with toxic megacolon often present in the
emergency department as having abdominal distention
superimposed on chronic or acute diarrhea. The diagnosis
should be considered in all such patients. The diagnosis is
usually based on thorough clinical history taking and
physical examination combined with plain abdominal
radiography. CT has a limited role, although it better
depicts the anatomic detail of transmural disease,
mesenteric involvement, and intraperitoneal complications
of inflammatory bowel disease.

Click on the image to enlarge

Video Endoscopic Sequence 41 of 110.

Bowel thickening is a nonspecific finding; it may be
encountered in a variety of colitides and other pathologies
of the bowel wall. The target sign is also nonspecific; it has
been reported in Crohn colitis. Mucosal ulceration
is difficult to detect with CT.

Click on the image to enlarge

Video Endoscopic Sequence 42 of 110.

Click on the image to enlarge

Video Endoscopic Sequence 43 of 110.

Toxic megacolon is the most severe manifestation of ulcerative colitis, diagnosed when the inflammation extends from the superficial mucosa into the submucosal and muscular layers of the colon. Toxic megacolon occurs more commonly in the setting of extensive colitis but can also occur with severe distal colitis. The manifestations of toxic megacolon include: fever, prostration, severe cramps, abdominal distention, and abdominal tenderness that may be localized, diffuse, or associated rebound tenderness. These toxic manifestations result from transmural extension of inflammation producing circular muscle paralysis and precipitating dilation along with a “tissue-paper” thin colonic wall.

Click on the image to enlarge

Video Endoscopic Sequence 44 of 110.

Click on the image to enlarge

Video Endoscopic Sequence 45 of 110.

Click on the image to enlarge

Video Endoscopic Sequence 48 of 110.

Although many CT findings in ulcerative colitis are striking,
they are not considered specific. Some features do suggest
a diagnosis of IBD, and specific features may indicate a
single diagnosis of ulcerative colitis with a high degree of
confidence. The halo sign typically occurs in ulcerative
colitis.

Download the video clip by clicking on the image.

Video Endoscopic Sequence 49 of 110.

Image and video clip where is observed the perforation in
the transverse colon

Perforation and toxic megacolon are the most dreaded
complications of UC. Perforation can occur in the presence
of fulminating disease, even in the absence of toxic
megacolon. The mortality rate is 50% if perforation occurs.

Surgical intervention with colectomy is indicated in patients
who are intractable to medical therapy and for those with
massive hemorrhage, colonic perforation, unresolving toxic
megacolon, and dysplasia or carcinoma.

Download the video clips by clicking on the images.

Video Endoscopic Sequence 50 of 110.

Suturing to be avoided major contamination during the surgery.

Download the video clips by clicking on the images.

Video Endoscopic Sequence 51 of 110.

Emergency surgery involves total colectomy and end ileostomy as a life-saving procedure. Patients presenting with severe acute colitis for their first attack are the most likely to require colectomy (up to 25%). Following recovery from a total colectomy, thought must be given to the fate of the remaining rectum as it can continue to cause bloody anal discharge if the inflammation fails to subside and it remains a site of potential cancer, although the risk is about 5% over 20 years. There are four options for the residual rectum:

Elective

In the elective situation there are three surgical options:
1. Panproctocolectomy and end ileostomy
2. Total colectomy and ileorectal anastomosis
3. Panproctocolectomy and ileal pouch–anal anastomosis

The choice of operation depends on patient fitness,
sphincter function and choice. All three elective procedures
can now be carried out with laparoscopic assistance.

Video Endoscopic Sequence 52 of 110.

Ileostomy

Both fulminant colitis and toxic megacolon are regarded as
the sequelae of colitis in which irreversible changes in the
whole thickness of colonic wall have occurred. These
condition both call for an immediate, emergent surgical
intervention. Until recently the procedure of choice in this
acute phase of the disease was colectomy with Brooke
ileostomy and Hartmann type closure of the distal rectum.
Colectomy with ileal pouch anal anastomosis was reserved
only for elective surgery.

Video Endoscopic Sequence 53 of 110.

The improvement in surgical technique, but first of all
widespread of stapling devices, have shortened the time of
operation and simplified the procedure, so that creation of
an ileal reservoir is currently more often performed as a
one step procedure and without an increased risk.

Video Endoscopic Sequence 54 of 110.

Gross Description:

Colon of 95 cm with 8 cm of diameter at the level of the
cecum, 6 cm. in the transverse and descending colon 5 cm.
in their averages diameters. At the level of transverse
mesocolon there were purulent exudate at site of two
stitches of silk in area of perforacion of 1.2 cm long.

Panoramic view of the surgical specimen showing theentire
colon which was resected from the recto-sigmoid junctio to
20 cm of terminal ileum

Twenty percent of patients require colectomy, which is curative.

Download the video clips by clicking on the images.

Video Endoscopic Sequence 55 of 110.

The cut of the surgical piece begins.

Surgical intervention with colectomy is indicated in
patients who are intractable to medical therapy and for
those with massive hemorrhage, colonic perforation,
unresolving toxic megacolon, and dysplasia or carcinoma.

Download the video clips by clicking on the images.

Video Endoscopic Sequence 56 of 110.

We continue with the cut of the surgical piece

The most widely used criteria for the clinical diagnosis of
toxic megacolon are: Radiographic evidence of colonic
distension PLUS at least three of the following: Fever
>38şC Heart rate >120 beats/min Neutrophilic leukocytosis
>10,500/microL Anemia PLUS at least one of the
following: Dehydration Altered sensorium Electrolyte
disturbances Hypotension.

Download the video clip by clicking on the image.

Video Endoscopic Sequence 57 of 110.

The Cecum

Rapid development of ulcerative colitis with
pseudopolyposis in the ascending colon and cecum

There are multiple ulcers and pseudopolyps that was not
seen in the colonoscopy performed 18 days before, that
indicates the inflammatory process was progressive in
spite of the treatment with high doses of prednisona.

Download the video clips by clicking on the images.

Video Endoscopic Sequence 58 of 110.

The ileocecal valve has been opened, being observed some
centimeters of the terminal ileum.

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Video Endoscopic Sequence 59 of 110.

The ileocecal valve with a portion of terminal ileum that is not involved.

Ulcerative colitis is confined to the large bowel although up
to 30 cm of terminal ileum can be involved with “backwash
ileitis”

Mural thickening of the terminal ileum may be visualized
in 10-25% of patients; such thickening is caused
by backwash ileitis, which occurs as a result of the reflux
of colonic contents into the distal ileum. Abscesses and
pseudodiverticula are not features of ulcerative colitis;
they occur almost exclusively in Crohn colitis.

Download the video clips by clicking on the images.

Video Endoscopic Sequence 60 of 110.

The treatment of ulcerative colitis in both the acute and
chronic phases of the disease is rather difficult. There is
uniform agreement that these patients should be treated
medically as long as they show improvement and continue
in a satisfactory condition. It should be admitted, however,
that some patients do not respond satisfactorily to any or
all of the medical measures that may be employed. 

Download the video clips by clicking on the images.

Video Endoscopic Sequence 61 of 110.

Download the video clip by clicking on the image.

Download the video clips by clicking on the images.

Video Endoscopic Sequence 62 of 110.

Extensive Pseudopolyposis

At section there were islands or pseudopolyps of mucosa,
red dark, a lot with ulceration and perforation at the level
of the transverse colon (sutures site). at the cecum the
injuries were less severe retaining areas of edematous
and hiperemic mucosa with irregular ulcers. The
pseudopolyps varied between 0.5 and 2 cm diameter.
There were appreciated multiple hemorragic areas and
yellowish material on the islands of mucosae and ulcerated
zones. The ileocecal valve was edematous.

More details download the video clip clicking on the image

Video Endoscopic Sequence 63 of 110.

Macroscopic Features of Ulcerative Colitis Severe Activities

The opened colon shows numerous enlarged or elongated polyps

Ulcerative Colitis (UC).

Generalized polyposis, generally considered to be an
asymptomatic sequela of ulcerative colitis, can also be
associated with severe attacks of colitis.

Download the video clips by clicking on the images.

Video Endoscopic Sequence 64 of 110.

Extensive ulcerative colitis (UC) with pseudopolyposis

The severity of the inflammatory reaction seen correlates well with the clinical course of the disease. Most of the cardinal features of UC include:

Inflammation limited to the mucosa and superficial submucosa although deeper layers can be involved in fulminant colitis.

Diffuse and severe distortion of crypt architecture,
although this can take 6/52 to develop.

Diffuse and severe reduction in crypt density.

Heavy infiltration of inflammatory cells in the
lamina propria. In active disease neutrophils are
prevalent and these can form crypt abscesses which
are a reliable indicator of disease severity.

Severe mucin depletion.

Superficial ulceration in active disease.

Download the video clips by clicking on the images.

Video Endoscopic Sequence 65 of 110.

The opened resected specimen of the colon with dilatation
and extensive ulcerations and pseudopolyposis.

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".

Download the video clip by clicking on the image.

Video Endoscopic Sequence 66 of 110.

Approach to the pseudopolyps and the extensive ulcers

At higher magnification, the pseudopolyps can be seen
clearly as raised red islands of inflamed mucosa. Between
the pseudopolyps is only remaining muscularis.

Download the video clips by clicking on the images.

Video Endoscopic Sequence 67 of 110.

Pseudopolyps are seen here in a case of severe ulcerative
colitis. The remaining mucosa has been ulcerated away
and is hyperemic. A colonoscopic view of active ulcerative
colitis, but not so eroded as to produce pseudopolyps.

Download the video clip by clicking on the image.

Video Endoscopic Sequence 68 of 110.

The clinical severity of ulcerative colitis depends on both the length of colon involved and the severity of colonic inflammation.

The symptomatic criteria most commonly used to define the severity of disease were established by Truelove and Witts to assess improvement in the first clinical trial of cortisone for ulcerative colitis and remain useful to classify severity in clinical practice. The criteria define mild and severe disease activity with moderate activity being present when there are intermediate symptoms. These criteria may also be modified to include fulminant colitis.

Most patients present with moderately severe symptoms of ulcerative colitis and the course is, typically, intermittent with the majority of patients maintained in clinical remission or having mild symptoms despite a 90% likelihood of relapse if medical therapy is not maintained.

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Video Endoscopic Sequence 69 of 110.

Another picture of the surgical specimen from the rectosigmoid juntion to the terminal ilium.

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Video Endoscopic Sequence 70 of 110.

Download the video clip

Mural thickening is a common manifestation of
inflammatory bowel disease; in general, however,
ulcerative colitis produces less wall thickening than does
Crohn disease.

Download the video clips by clicking on the images.

Video Endoscopic Sequence 71 of 110.

Photographic Gallery

Macroscopic appearance of the resected colon

The following pictures can be enlarge by clicking on them

Video Endoscopic Sequence 72 of 110.

Colectomy Specimen

The cecal appendix average 7x0.5 cm with hyperemia,
the lumen was reduced. The ileon were 16 cm. long and
2 cm. in diameter. The mucosae shows edema and erosions.
Ileocecal ganglia were hyperemics.

To enlarge the image click on it

Video Endoscopic Sequence 73 of 110.

This picture shows the surgical incision of the recto-sigmoid junction.

Video Endoscopic Sequence 74 of 110.

Colectomy Specimen

Gross examination of the large intestine in non-neoplastic
conditions can also yield valuable diagnostic information,
particularly in the classification of inflammatory bowe
disease.

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Video Endoscopic Sequence 75 of 110.

Macroscopic Description

The distribution, extent, and nature of macroscopic changes in inflammatory bowel disease are frequently important diagnostic features. The following guidelines primarily relate to resections performed for Crohn's disease and ulcerative colitis. The specimen nature (extent of surgical resection) should be recorded. Care should be taken to identify and document the distribution of serosal fat wrapping, severe dilatation, mural thickening or stricture formation, ulcers, perforation, pseudopolyps, and mucosal cobblestoning. Both ulcerative colitis and Crohn's disease are associated with an increased risk of colorectal cancer, and specimens should be examined carefully for any suspicious lesions.

Video Endoscopic Sequence 76 of 110.

This pictute shows the site of perforation

Thorough macroscopic descriptions have a tendency to
become lengthy, and specimen photography can prove
extremely useful in this situation, providing an invaluable
visual record for clinicopathological meetings. The
appearance of fixed specimens can be improved by
immersing in 70% ethyl alcohol for colour restoration
before being photographed.

Video Endoscopic Sequence 77 of 110.

Again the site of perforation

Video Endoscopic Sequence 78 of 110.

The silk suturing where is the site of perforation

Video Endoscopic Sequence 79 of 110.

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Video Endoscopic Sequence 80 of 110.

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Video Endoscopic Sequence 81 of 110.

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Video Endoscopic Sequence 82 of 110.

Ulcerative colitis is a disease that is often encountered by endoscopists. Although endoscopic features of acute self-limiting infectious colitis overlap considerably with those of idiopathic inflammatory bowel disease, there are inflammatory changes and patterns that are suggestive of ulcerative colitis. Three cases are presented with the typical endoscopic features of ulcerative colitis with low, moderate, and severe activities.

Video Endoscopic Sequence 83 of 110.

Polypoid and pseudopolypoid manifestations of
inflammatory bowel disease. (pubmed).

The polypoid manifestations of the idiopathic inflammatory bowel diseases (ulcerative colitis and Crohn disease) are often confusing. Inflammatory polyps project above the level of the surrounding mucosa. Pseudopolyposis (in ulcerative colitis) or a cobblestone appearance (in Crohn disease) results when extensive ulceration develops and only scattered islands of relatively normal mucosa remain; thus, the ulcerated areas may be falsely perceived as the baseline and the islands as polyps. Postinflammatory (filiform) polyps--fingerlike projections of submucosa covered by mucosa on all sides--reflect healing of undermined mucosal and submucosal remnants and ulcers and are almost always multiple. Patients with ulcerative colitis or Crohn disease are at increased risk for developing adenocarcinoma.

Video Endoscopic Sequence 84 of 110.

Occasionally, dysplasia occurs as a polypoid lesion.
Dysplasia of the colon (mucosal atypia) is a histologic
marker highly associated with adenocarcinoma. Because
differentiating adenocarcinoma and dysplasia from
inflammatory or postinflammatory polyps is sometimes
difficult or impossible, endoscopy and biopsy are usually
recommended for definitive diagnosis of suspicious lesions.

Video Endoscopic Sequence 85 of 110.

Image of Surgical Specimen: multiple and extensive pseudopolyposis in ulcerative colitis.

Video Endoscopic Sequence 86 of 110.

View of Surgical Specimen: multiple and extensive pseudopolyposis in ulcerative colitis.

Video Endoscopic Sequence 87 of 110.

Photograph shows continuous regions of ulceration and
pseudopolyps throughout the total colectomy specimen,
with the most severe changes evident in the ascending and
transverse colon portions, and dilatation indicative of
megacolon.

Video Endoscopic Sequence 88 of 110.

Pseudopolyposis is probably the most common local
complication of ulcerative colitis. The reported incidence
varies from 12,5% to 74%, depending on the diagnostic
criteria employed and patients groups studied.
Pseudopolyps represent polypoid edematous mucosal tags,
regenerative mucosal islands between areas of ulceration
or heaped-up granulation tissue covered by glandular
epithelium (Dukes, 1954). They may be seen in the active
or quiescent phase of the disease and can be diffuse or
local in distribution. There is a direct relation between
severity and extension of the disease and the incidence of
pseudopolyposis, although the outcome of severe attacks
of ulcerative colitis in the presence of pseudopolyps has
been found to be more favourable.

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Video Endoscopic Sequence 89 of 110.

Inflammatory Pseudopolyposis following a chronic severe
case of ulcerative colitis.

The majority of evidence supports the concept that
pseudopolyposis per se is not a precancerous change and
the discovery of pseudopolyps in itself does not require
any specific treatment.

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Video Endoscopic Sequence 90 of 110.

Image of Surgical Specimen: multiple and extensive pseudopolyposis in ulcerative colitis.

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Video Endoscopic Sequence 91 of 110.

Although pseudopolyps are the commonest sequelae of
ulcerative colitis, the occurrence of localized exuberant
collections of pseudopolyps, giving rise to large
intraluminal masses, is a rare finding during the course of
the disease. The term ‘‘Localized giant pseudopolyposis
has been applied to describe this phenomenon.

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Video Endoscopic Sequence 92 of 110.

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Video Endoscopic Sequence 93 of 110.

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Video Endoscopic Sequence 94 of 110.

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Video Endoscopic Sequence 95 of 110.

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Video Endoscopic Sequence 96 of 110.

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Video Endoscopic Sequence 97 of 110.

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Video Endoscopic Sequence 98 of 110.

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Video Endoscopic Sequence 99 of 110.

This image as well as the video clip was taken by the pathologist .

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Video Endoscopic Sequence 100 of 110.

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Video Endoscopic Sequence 101 of 110.

Video Endoscopic Sequence 102 of 110.

There are severe inflammatory process with extensive
ulcerations leaving islands or pseudopolyps of mucosa with
of granulacion tissue. there are extensive areas of
hiperemic and hemorragic tissue. there are microabsces
and purulent surface and in the ulcers.

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Video Endoscopic Sequence 103 of 110.

The inflamatory process goes deep into the own muscle
and pericolic adiposse tissue with perforacion at the level
of the transverse colon. the cecal appendix has chronic
inflamation similar to the ileal mucosa with erosions. 

The lymphonodes have chronic inflamacion. The ileal limit
has chronic inflamation. The surgical limit at the sigmoid
end has chronic inflamation and is extensively ulcerated.

Video Endoscopic Sequence 104 of 110.

Video Endoscopic Sequence 105 of 110.

Video Endoscopic Sequence 106 of 110.

Video Endoscopic Sequence 108 of 110.

Video Endoscopic Sequence 109 of 110.

Video Endoscopic Sequence 110 of 110.

Secuencia Video Endoscópica 110 de 110.

Detalle del trayecto de la perforación de la pared del colon con exudado purulento.