Ulcerative colitis (UC) is a form of inflammatory bowel disease. Inflammation always starts at rectum (hence it is the most common site for UC), never spreads beyond ileocaecal valve and is continuous. The peak incidence of ulcerative colitis is in people aged 15-25 years and in those aged 55-65 years.

The initial presentation is usually following insidious and intermittent symptoms. Features include:

• bloody diarrhoea
• urgency
• tenesmus
• abdominal pain, particularly in the left lower quadrant
• extra-intestinal features (see below)

Endoscopy

• colonoscopy + biopsy is generally done for diagnosis
• however in patients with severe colitis colonoscopy should be avoided due to the risk of perforation - a flexible sigmoidoscopy is preferred
• typical findings:
  • red, raw mucosa, bleeds easily
  • no inflammation beyond submucosa (unless fulminant disease)
  • widespread ulceration with preservation of adjacent mucosa which has the appearance of polyps ('pseudopolyps')
  • inflammatory cell infiltrate in lamina propria
  • neutrophils migrate through the walls of glands to form crypt abscesses
  • depletion of goblet cells and mucin from gland epithelium
  • granulomas are infrequent

Barium enema

• loss of haustrations
• superficial ulceration, 'pseudopolyps'
• long standing disease: colon is narrow and short -'drainpipe colon'

Abdominal x-ray from a patient with ulcerative colitis showing lead pipe appearance of the colon (red arrows). Ankylosis of the left sacroiliac joint and partial ankylosis on the right (yellow arrow), reinforcing the link with sacroiliitis.

Barium enema from a patient with ulcerative colitis. The whole colon, without skips is affected by an irregular mucosa with loss of normal haustral markings.

Questions regarding the 'extra-intestinal' features of inflammatory bowel disease are common:

Episcleritis is more common in CD | | Unrelated to disease activity | Arthritis: polyarticular, symmetric Uveitis Pyoderma gangrenosum Clubbing Primary sclerosing cholangitis | Primary sclerosing cholangitis is much more common in UC

Uveitis is more common in UC |