C h a p t e r 2 9
Disorders of Gastrointestinal Function
709
colon (pancolitis). The inflammatory process tends to be
confluent and continuous instead of skipping areas, as it
does in Crohn disease.
Characteristic of the disease are lesions that form in
the crypts of Lieberkühn in the base of the mucosal layer
(see Chapter 28, Fig. 28-11). The inflammatory process
leads to the formation of pinpoint mucosal hemor-
rhages, which in time suppurate and develop into crypt
abscesses. These inflammatory lesions may become
necrotic and ulcerate. Although the ulcerations usually
are superficial, they often extend to nearby tissues, caus-
ing large denuded areas (Fig. 29-7). As a result of the
inflammatory process, the mucosal layer often develops
tonguelike projections that resemble polyps and there-
fore are called
pseudopolyps.
The bowel wall thickens
in response to repeated episodes of colitis.
Clinical Manifestations.
Ulcerative colitis typically
presents as a relapsing disorder marked by attacks of
diarrhea. The diarrhea may persist for days, weeks,
or months and then subside, only to recur after an
asymptomatic interval of several months to years or
even decades.
8,29,30
Because ulcerative colitis affects the
mucosal layer of the bowel, the stools typically contain
blood and mucus. Nocturnal diarrhea usually occurs
when daytime symptoms are severe. There may be mild
abdominal cramping and fecal incontinence. Anorexia,
weakness, and fatigability are common.
Based on clinical and endoscopic findings, the disease
is characterized by its severity and extent. Severity is
defined as mild, moderate, or severe.
8
The most common
form of the disease is the mild form, in which the person
has less than four formed or liquid stools daily, with
intermittent rectal bleeding. Because of rectal inflamma-
tion there may be urgency, accompanied by lower left
quadrant cramping. Persons with moderate disease have
more severe diarrhea and bleeding. Abdominal pain and
tenderness may be present, but not severe. There may
be fever and anemia. Persons with severe disease have
more than 6 bloody bowel movements a day, resulting
in severe anemia, hypovolemia, and impaired nutrition
with hypoalbuminemia. A subset of persons with ulcer-
ative colitis develop a more fulminant form of the dis-
ease with rapid progression over a matter of weeks to
fever, prominent hypovolemia, hemorrhaging requiring
transfusion, and abdominal distention with tenderness.
Complications.
Cancer of the colon is one of the feared
complications of ulcerative colitis.
6–8,29
Because of the
relatively high risk for development of cancer, regular
annual or biannual surveillance colonoscopies with
multiple biopsies are recommended for persons with
extensive colitis, beginning 8 to 10 years after diagnosis.
Diagnosis and Treatment.
Diagnosis of ulcerative
colitis is based on history and physical examination.
The diagnosis usually is confirmed by sigmoidoscopy,
colonoscopy, biopsy, and negative stool examinations
for infectious or other causes. Colonoscopy should not
be performed on persons with severe disease because of
the danger of perforation, but may be performed after
demonstrated improvement to determine the extent of
disease and need for subsequent cancer surveillance.
8,29,30
Treatment depends on the extent of the disease and
severity of symptoms. It includes measures to control
the acute manifestations of the disease and prevent
recurrence. Some people with mild to moderate symp-
toms are able to control their symptoms simply by
avoiding caffeine, lactose (milk), highly spiced foods,
and gas-forming foods. Fiber supplements may be used
to decrease diarrhea and rectal symptoms. Surgical
treatment (i.e., removal of the rectum and entire colon)
with the creation of an ileostomy or ileoanal anastomo-
sis may be required for persons who do not respond to
medications and conservative methods of treatment.
The medications used in treatment of ulcerative colitis
are similar to those used in the treatment of Crohn dis-
ease. They include the nonabsorbable 5-ASA compounds
(e.g., sulfasalazine, mesalamine).
8,29,30
The corticosteroids
are used selectively to lessen the acute inflammatory
response. Many of these medications can be administered
rectally by suppository or enema. Immunomodulating
drugs and anti-TNF therapies may be used to treat per-
sons with severe colitis. Unlike Crohn disease, ulcerative
colitis may respond to probiotic (oral preparations of
bacteria contained in the normal gut flora) therapy.
29
Infectious Enterocolitis
A number of microbial agents, including viruses, bacte-
ria, and protozoa, can infect the gastrointestinal tract,
causing a broad range of symptoms including diar-
rhea, abdominal pain, perianal discomfort, ulceration,
and hemorrhage. Infectious enterocolitis is a global
problem, causing more than 3 million deaths annually
and accounting for up to one half of deaths in children
younger than 5 years in some countries.
6
Although less
common in industrialized countries, these disorders still
FIGURE 29-7.
Ulcerative colitis. Prominent erythema and
ulceration of the colon begin in the ascending colon and are
most severe in the rectosigmoid area (From Rubin R.The
gastrointestinal tract. In: Rubin R, Strayer DS, eds. Rubin’s
Pathology: Clinicopathologic Foundations of Medicine. 6th ed.
Philadelphia, PA: Wolters Kluwer Health | Lippincott Williams &
Wilkins; 2012:656.)
