Gastrointestinal · Year 2 · from Gastrointestinal
Case 2: Ulcerative Colitis
Patient Presentation
Demographics: 35-year-old male
Chief Complaint: Bloody diarrhea, urgency, and tenesmus for 3 weeks
History of Present Illness: The patient reports 8-10 bloody, mucoid stools daily with severe urgency and a constant feeling of incomplete evacuation (tenesmus). He has nocturnal bowel movements that wake him from sleep. He has crampy left-sided abdominal pain that precedes bowel movements. He has had a low-grade fever and has lost 8 pounds.
Past Medical History: None
Social History: Non-smoker (quit 2 years ago), social alcohol
Physical Examination
- Vital Signs: BP 115/72 mmHg, HR 102 bpm, Temperature 38.1C, BMI 24
- General: Appears uncomfortable, mildly pale
- Abdomen: Mild left lower quadrant tenderness, hyperactive bowel sounds, no distension or peritoneal signs
- Rectal: Bright red blood on glove, no masses
Workup and Results
- CBC: Hemoglobin 11.4 g/dL, WBC 13,500, Platelets 410,000
- CRP: 62 mg/L, ESR 48 mm/hr
- Albumin: 3.1 g/dL
- Stool Studies: Negative for C. difficile, bacterial pathogens, ova/parasites
- Fecal Calprotectin: 890 mcg/g
- Colonoscopy: Continuous inflammation from rectum extending to splenic flexure; erythema, edema, loss of vascular pattern, friability, and superficial ulcerations; clear demarcation at splenic flexure with normal proximal colon
- Histopathology: Crypt abscesses, crypt architectural distortion, inflammation limited to mucosa
Colonoscopic appearance of active ulcerative colitis showing diffuse erythema, loss of normal vascular pattern, mucosal friability with contact bleeding, and superficial ulcerations. Note the continuous nature of inflammation.
Image Source: Wikimedia Commons, CC BY-SA 3.0
Diagnosis
Ulcerative Colitis (Left-sided/Moderate-Severe)
Clinical Correlation
Ulcerative colitis is characterized by continuous mucosal inflammation beginning at the rectum and extending proximally. Key distinguishing features from Crohn's include: involvement limited to colon, always involves rectum, continuous (not skip) lesions, inflammation confined to mucosa and submucosa, crypt abscesses on histology, and absence of granulomas. The extent is classified as proctitis, left-sided (to splenic flexure), or pancolitis. Severity is assessed by Truelove-Witts criteria or Mayo score based on stool frequency, blood, endoscopic findings, and physician assessment. This patient has moderate-severe disease requiring systemic therapy.
Treatment
- Exclude infection (stool studies including C. difficile)
- Induction therapy options for moderate-severe disease:
- IV corticosteroids (methylprednisolone 40-60 mg daily) for acute flare
- If steroid-refractory: infliximab or cyclosporine as rescue therapy
- Maintenance therapy: anti-TNF (infliximab, adalimumab), vedolizumab (gut-selective), or tofacitinib (JAK inhibitor)
- 5-ASA (mesalamine) may be added for maintenance but insufficient alone for this severity
- Assess for toxic megacolon (abdominal X-ray if suspected)
- Surgical consultation if medical therapy fails (colectomy is curative)
- Colonoscopic surveillance for dysplasia starting 8 years after diagnosis