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Ulcerative colitis (UC) is a disorder characterized by diffuse mucosal inflammation limited to the colon. UC is usually a chronic disease which involves the rectum and may extend proximally in a symmetrical, circumferential, and uninterrupted pattern to involve parts or all of the large intestine. The hallmark clinical symptom is bloody diarrhea often with prominent symptoms of rectal urgency and tenesmus (painful straining at stool). The
In a patient presenting with persistent bloody diarrhea, rectal urgency, or tenesmus, stool examinations and sigmoidoscopy and biopsy should be performed to confirm the presence of a colitis and to rule out infectious causes. Characteristic endoscopic and histologic findings with negative evaluation for infectious causes will suggest the diagnosis of ulcerative colitis.
The diagnosis of UC is suspected on clinical grounds and supported by the appropriate findings on proctosigmoidoscopy or colonoscopy, biopsy, and by negative stool examination for infectious causes ulserative.
Proctosigmoidoscopy or colonoscopy will reveal the mucosal changes characteristic of ulcerative colitis, consisting of loss of the typical vascular pattern, granularity, friability, and
Goals of treatment are directed at inducing and then maintaining remission of symptoms and mucosal inflammation. Once the diagnosis of UC is confirmed, the anatomic extent is assessed endoscopically. The key question to be addressed at this point is whether the inflammation is "distal" (i.e., limited to below the splenic flexure and thus within reach of topical therapy) or
Patients with mild to moderate distal colitis may be treated with either oral aminosalicylates, topical mesalamine, or topical steroids. In patients refractory to oral aminosalicylates or topical corticosteroids, mesalamine enemas may still be effective. The unusual patient who is refractory to all of the above agents in maximal doses may require treatment with oral prednisone
Mesalamine suppositories in a dose of 500 mg twice daily are effective in the maintenance of remission, in patients with proctitis, whereas mesalamine enemas (2-4 grams) are effective in patients with distal colitis. Sulfasalazine (2-4 g/day) and mesalamine (1.5-4 g/day) are also effective in maintaining remission, whereas topical corticosteroids, on the other hand, have
Patients with mild to moderate extensive colitis should begin therapy with oral sulfasalazine in daily doses titrated up to 4-6 g/day, or an alternate aminosalicylate in doses up to 4.8 g/day. Oral steroids are generally reserved for patients who are refractory to oral aminosalicylates with or without topical therapy, or for patients whose symptoms are so troubling as to demand a "quick fix." 6-Mercaptopurine (6-MP) or azathioprine are effective for patients who do not respond to oral prednisone but are not so acutely ill as to
When inflammation extends proximal to the reach of topical therapy (i.e., middescending colon-splenic flexure) oral therapy is required, either solely or in combination with topical therapy (though this latter option has not
When the acute attack is controlled, a maintenance regimen is usually required, especially in patients with severe, extensive, or relapsing disease. Sulfasalazine, olsalazine, or mesalamine are all effective in reducing relapses. As a rule, patients should not be treated chronically with steroids. Azathioprine or 6-MP may be useful as steroid-sparing agents for steroid-dependent patients, and
The patient with severe colitis refractory to maximal oral treatment with prednisone, oral aminosalicylate drugs, and topical medications, or the patient who presents with toxicity, should be
Absolute indications for surgery are exsanguinating hemorrhage, perforation, and documented or strongly suspected carcinoma. Other indications for surgery are severe colitis with or