Key Points

• Chronic, relapsing-remitting inflammatory bowel disease confined to the colonic mucosa, starting in the rectum.
• Montreal classification assesses extent (E1 proctitis, E2 left-sided, E3 extensive) and severity (S0–S3 based on stool frequency and systemic signs).
• Diagnosis relies on history, labs (CBC, ESR/CRP, fecal calprotectin), endoscopy with biopsy, and exclusion of infectious etiologies.
• Induction therapies: 5-ASA, corticosteroids, advanced biologics (anti-TNF, vedolizumab, ustekinumab) and small molecules (tofacitinib).
• Maintenance: 5-ASA for mild disease; immunomodulators (azathioprine, 6-MP) and biologics for moderate–severe cases.
• Surgical proctocolectomy with ileal pouch–anal anastomosis is curative for refractory or dysplastic disease.
• Long-term surveillance colonoscopy essential to mitigate colorectal cancer risk after 8 years of disease in extensive colitis.

Introduction

Ulcerative colitis (UC) is an idiopathic, chronic inflammatory disease of the colon characterized by continuous mucosal ulceration and superficial inflammation. Population prevalence in North America and Europe ranges from 120 to 200 cases per 100,000 persons, with rising incidence in Asia. The disease often presents in young adults but can occur at any age.

Etiology and Pathogenesis

• Genetic predisposition: multiple susceptibility loci (e.g., HLA-DRB101:03, IL23R*).
• Dysregulated mucosal immunity: Th2-skewed cytokine profile (IL-5, IL-13) and innate immune activation.
• Barrier dysfunction: tight junction alterations, increased intestinal permeability.
• Microbiome alterations: reduced Firmicutes, increased Proteobacteria.
• Environmental triggers: diet, smoking cessation (protective effect), antibiotics.

Classification and Severity

Montreal Classification (2005)

• Extent:
• E1 (Ulcerative proctitis): involvement limited to rectum.
• E2 (Left-sided colitis): distal to splenic flexure.

• E3 (Extensive colitis): extends proximal to splenic flexure.

• Severity (Truelove & Witts criteria simplified):

• S0: remission.
• S1 (Mild): ≤4 stools/day ± mild rectal bleeding, no systemic signs.
• S2 (Moderate): 4–6 stools/day, minimal systemic signs.
• S3 (Severe): ≥6 bloody stools/day, tachycardia, fever, anemia, elevated ESR.

Clinical Presentation

Gastrointestinal Symptoms

• Bloody diarrhea, urgency, tenesmus.
• Abdominal cramps, predominantly left lower quadrant.
• Weight loss, malaise.

Extraintestinal Manifestations (EIMs)

• Musculoskeletal: peripheral arthritis, axial spondyloarthritis.
• Dermatologic: erythema nodosum, pyoderma gangrenosum.
• Ophthalmic: uveitis, episcleritis.
• Hepatobiliary: primary sclerosing cholangitis.
• Thromboembolic risk: deep vein thrombosis, pulmonary embolism.

Diagnostic Evaluation

Laboratory Tests

• CBC: anemia, leukocytosis or leukopenia.
• Inflammatory markers: ESR, CRP.
• Fecal calprotectin or lactoferrin: correlate with mucosal inflammation.
• Stool studies: rule out C. difficile, viral, bacterial pathogens.

Endoscopy

• Colonoscopy and flexible sigmoidoscopy:
• Continuous mucosal erythema, friability, ulceration, and pseudopolyps.
• Biopsy: crypt architectural distortion, crypt abscesses, basal plasmacytosis.

Imaging

• CT/MRI enterography: assess extent, exclude complications (toxic megacolon, perforation).
• Transabdominal ultrasound: adjunct in select centers.

Management

Induction Therapy

Mild–Moderate UC

• Topical and/or oral 5-aminosalicylic acid (mesalamine, sulfasalazine).
• Budesonide MMX for left-sided colitis.

Moderate–Severe UC

• Systemic corticosteroids (prednisone) for induction; taper over 8–10 weeks.
• Biologics:
• Anti-TNFα: infliximab, adalimumab, golimumab.
• Anti-integrin: vedolizumab.
• Anti-IL12/23: ustekinumab.
• Small molecules: tofacitinib (JAK inhibitor).

Maintenance Therapy

• 5-ASA for mild disease.
• Thiopurines (azathioprine, 6-MP) or methotrexate for steroid‐sparing.
• Continue biologics or small molecules; therapeutic drug monitoring recommended.

Surgical Management

• Indications: refractory disease, severe acute colitis, dysplasia or cancer, toxic megacolon.
• Restorative proctocolectomy with ileal pouch–anal anastomosis (IPAA): curative.
• Permanent ileostomy if IPAA contraindicated.

Surveillance and Long-Term Care

• Colonoscopic surveillance intervals:
• After 8 years disease for E3, after 10–15 years for E2.
• Dysplasia: annual or biennial based on risk.
• Vaccinations: influenza, pneumococcal, HPV, and others per immunosuppression profile.
• Bone health: monitor for osteoporosis in long‐term steroid users.

Nursing Considerations

• Monitor hydration status, stool output, and vital signs.
• Educate on medication adherence and administration (oral, rectal therapies).
• Skin care for perianal irritation with high-frequency diarrhea.
• Nutritional support: correct deficiencies (iron, vitamin D, B12).
• Psychosocial support: address anxiety, depression, and quality-of-life issues.

Patient Education

• Disease nature: relapsing-remitting course.
• Recognizing flare triggers: medication noncompliance, infections, stress.
• Lifestyle modifications: balanced diet, smoking cessation, exercise.
• Importance of routine surveillance and follow-up care.

References

1. Ungaro R, Mehandru S, Allen PB, Peyrin-Biroulet L, Colombel JF. Ulcerative colitis. Lancet. 2017;389(10080):1756–1770.
2. Rubin DT, Ananthakrishnan AN, Siegel CA, Sauer BG, Long MD. ACG Clinical Guideline: Ulcerative Colitis in Adults. Am J Gastroenterol. 2019;114(3):384–413.
3. Magro F, Gionchetti P, Eliakim R, et al. Third European Evidence-based Consensus on Diagnosis and Management of Ulcerative Colitis. J Crohns Colitis. 2017;11(6):649–670.
4. Torres J, Mehandru S, Colombel JF, Peyrin-Biroulet L. Crohn’s disease. Lancet. 2017;389(10080):1741–1755.
5. Loftus EV Jr, Sandborn WJ. Epidemiology of inflammatory bowel disease. Gastroenterology. 2002;122(4):1820–1827.