Ulcerative Colitis

Basics

Ulcerative colitis (UC) is a chronic inflammatory bowel disease (IBD) characterized by diffuse mucosal inflammatory changes limited to the colon.
Most cases involve the rectum and may extend proximally in a continuous fashion involving part or the entire large intestine (1).
Frequently manifested by recurrent episodes of bloody and mucoid diarrhea often associated with abdominal pain, rectal urgency, stool incontinence, fever, and weight loss
Clinical course includes exacerbations and spontaneous or treatment induced remissions.
Colonic involvement is universal and may be accompanied by other extraintestinal manifestations.

Although incidence of UC was highest in Western nations, incidence has been increasing worldwide:

Due to young age at diagnosis and relatively low mortality, prevalence continues to rise:

Idiopathic inflammatory disorder hypothesized to result from immune dysfunction in a genetically predisposed individual in response to environmental triggers and gut microbiome alterations
Inflammation starts in rectum (>95% of patients) and extends proximally (50% rectosigmoid), and 20% have pancolitis. Rectum may be spared in <5% adults and up to 1/3 of pediatric patients.

Polygenic disease with >200 genetic loci in genome-wide studies; increased risk with Turner syndrome
Higher incidence in first-degree relative.

Peak incidence at age 20 to 40 years and second peak at age 50 to 80 years
Higher incidence in White and Ashkenazi Jewish populations; rising in Black and Latinx populations
Environmental risk factors include enteric infection, diet (Western diet, ultraprocessed foods), antibiotic use, lack of breastfeeding in infant, obesity, and NSAIDs use. Smoking may lower risk of UC.

Pregnancy Considerations

Patient should be advised to conceive during remission if planning a pregnancy; 3 to 6 months of remission before conception decreases risk of exacerbation during pregnancy (2).
There is increased risk of preterm delivery and small for gestational age in women with active disease.
Ideally, pregnant women should be monitored by both gastroenterologist and maternal-fetal medicine specialist (2).

Common: arthritis/arthralgias: small and large joints, sacroiliitis, aphthous ulcers, erythema nodosum, anemia, osteoporosis, fatty liver
Rare: episcleritis, scleritis and uveitis, autoimmune hepatitis, liver cirrhosis, primary sclerosing cholangitis (PSC), bile duct carcinoma, ankylosing spondylitis, pyoderma gangrenosum, colon cancer

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