ULCERATIVE COLITIS 1

ULCERATIVE COLITIS

INCIDENCE

The disease affects all age groups with highest incidence in  the

third and fourth decades.

The  average  annual  incidence rate for  ulcerative  colitis  in

whites varies from 6.5-20/1,00,000 in the west.

Incidence  of  ulcerative colitis in Jews is  about  three  times

higher and occurs more in females than in males.

Coloured races have a significantly lower incidence.

ETIOLOGY

The cause of ulcerative colitis is still uncertain.

*  There  is suspicion that allergy or hypersensitivity  plays  a

   role in the genesis of the disease.

*  Ulcerative colitis is probably a disease of  hyper-sensitivity

   or  an  autoimmune  phenomenon,  the  immune  response   being

   directed against colonic mucosa.

PATHOLOGY

Rectum  is  the  most  frequently  involved  organ  affected   by

ulcerative colitis.

*  Disease spreads proximally in more than half, the entire colon

   can be diseased.

*  The terminal ileum is involved for a short distance in 10%  of

   cases.

*  Grossly,  the serosal surface is essentially normal  early  in

   the  disease, in advanced cases, the bowel is  shortened;  the

   mesentery contracted, oedematous and thickened.

*  The  mucosal  surface in advanced chronic  ulcerative  colitis

   shows an abnormal appearance.

*  Blood and pus cover the irregular moth eaten mucosal surface.

*  There are irregular, shallow; linear ulcers intersperesed with

   islands   of  swollen  mucosa  "pseudo-polyps"   provide   the

   characteristics appearance.

HISTOLOGY

The  earliest  lesion  develops in the bases  of  the  crypts  of

Lieberkuhn,  neutrophilic  leukocytes  accumulate  in  the  crypt

lumen,  these  and eosinophis form the "crypts abscess"  and  may

rupture through the mucosal surface.

*  With progresion, numerous crypts are involved and large  areas

   of  their  walls break down, releasing the  exudate  into  the

   submucousa leading to ulceration.

*  As  the  disease  progresses  lymphocytes,  plasma  cells  and

   macrophages infiltrate the mucosa and sub-mucosa.

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LARGE INTESTINE Diagnostic studies

DIAGNOSTIC STUDIES

All  patients with suspected colonic or rectal  disorders  should

have  a complete history of their bowel complaints  and  physical

examination  including  pelvic anal rectal examination  with  the

finger and visualisation with a proctascope.

Stool  examination  for occult blood is  essential  in  suspected

cases of carcinoma. 

In  chronic  diarrhea  cases, blood level  of  gastic  vasoactive

intestinal  peptides  (VIF) and other enterohormones  may  be  of

diagnostic help.

BARIUM ENEMA

The  small  lesions may escape detection.  A  dialogue  with  the

radiologist will help him define his use of the correct  modality

(double contrast) and focus on the site of the lesion.

ENDOSCOPY

The use of this instrument for diagnosis and treatment has become

routine  in most equiped medical centres.  It requires a  trained

endososcopist   to  retrieve  diagnostic  data.   It  enables   a

visualisation of the entire colon from anus to cecum.  the  bowel

needs   to  be  cleaned  by  enema  and  bowel  irrigation   with

commercially available polyethyle glycal (PEG).

PRE-OPERATIVE PREPARATION

The  fecal bacterial content has a high colony count  nearly  one

third  of  the dry weight of feacus is because of  bacteria  thus

cleaning  using  PEG has become a safe and  effective  to  ensure

success in preparing the bowel for surgery.

ORAL

Oral use of neomysin, erythromycin or metronidazole are the  most

commonly  used  drugs for limiting  post-operative  infection  in

colonic  surgery these agents are administered at 1 pm, 2 pm  and

11 pm on the day prior to surgery.

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LARGE INTESTINES Anatomy

1. ANATOMY

The  colon  starts in the right lower abdomen and  completes  its

course  as an inverted C to end in the left lower  abdomen.   The

further  course is in the pelvis (pelvic colon) and continues  as

the rectum and anal canal.

1.1 ARTERIES + LYMPHNODES

The  cecum, colon rectum and pronimal anal canal  receive  their

arterial supply from branches of superior and inferior mesenteric

arteries, both are branches of the aorta (fig 19.1)  anastomosis

between  the  branches  from  a  continuous  marginal  artery  of

drummond the distribution of lymph glands is shown in fig 19.2.

1.2 CECUM

This  is the first part of the large intestines and Ileum end  in

it.   There  is an ileacecal muscular valve to  prevent  flow  of

local contents into the ileim.  The diameter of the cecum is  7-9

cms.   The appendix is placed at the medial posterior  aspect  of

the cecum.

Colon

Motility of the colon is aimed at providing maximum contact to the chyme (500-1500 per day) to the absorptive colon mucosa the final residue of 50-100cc the proximal part of colon provides surface for absorption of water and the distal half storage of fecus the motility is segmentation and bag like haustration.

Mass movement is a modified prostates that occurs 15 minutes after morning breaking fast. These mass movements in the colon occur as a result of gastro colic and duodenal colic reflex.

Colonic irritation can also cause mass movement this is seen in case of ulcerative colitis.

1.3 ASCENDING COLON

It  extends upwards from the cecum to reach the under surface  of

the  liver here it bends (Hepatic flexure) to course  transversly

access the upper abdomen as the Transverse colon.

1.4 TRANSVERSE COLON

This part of the colon starts at the hepatic flexure and ends  at

the splenic flexure in the left upper abdomen.  It measures 35 to

50  cms. in length.  It is a mobile portion of the colon  and  is

immobile at the hepatic and splenic flesures.

1.5 DESCENDING COLON

Proceeds  downwards from the splenic flexure, measures 20-25  cms

to end in the pelvic colon.

1.6 PELVIC COLON

It  is also called the sigmoid colon it is curved in the form  of

an  S and its length is variable from 10-30 cms. it ends  in  the

upper part of the rectum

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Small Intestines Peutz Jeagaer Syndrome

PUETZ JEGHERS SYNDROME

This  is an uncommon familial disease manifestated  by  polyposis

and  melanin spots on the oral mucosa, lips, palms of  the  hands

and soles of the feet.

Recurrent  colicky  abdominal  pain  due  to  polyps  leading  to

transient intussusception is the most frequent presentation.

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