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Ulcerative colitis

Definition
UC is a chronic relapsing-remitting IBD characterized by superficial mucosal ulceration extending from the rectum to proximal colon.
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Pathophysiology
The pathogenesis of UC is multifactorial and involves mutations in susceptibility genes, abnormalities in gut microbiota composition and host-microbiome interactions, as well as abnormalities in humoral and cellular adaptive immunity.
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Epidemiology
The highest incidence and prevalence of IBD are seen in the populations of Northern Europe and North America and the lowest in continental Asia. In the US, the incidence of UC is estimated at 8.8 cases per 100,000 person-years, while the prevalence is estimated at 286.3 persons per 100,000 population.
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Disease course
Inflammation and ulceration of the colonic mucosa may result in clinical manifestations of proctitis, proctosigmoiditis, left-sided colitis, pancolitis, severe rectal bleeding, toxic megacolon, and CRC, in addition to extraintestinal complications.
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Prognosis and risk of recurrence
Over 10-years, 50-55% of patients remit, approximately 37% follow a chronic intermittent course, and 6% develop a chronic continuous course. An estimated 20-30% of patients require colectomy after 25 years of disease activity. The standardized mortality ratio of patients with UC, as compared with the general population, is estimated at 2.78 (95% CI, 1.48-4.75).
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Key sources
The following summarized guidelines for the evaluation and management of ulcerative colitis are prepared by our editorial team based on guidelines from the American Gastroenterological Association (AGA 2024; 2023; 2020; 2017), the European Society for Clinical Nutrition and Metabolism (ESPEN 2023), the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN 2023), the European Crohn's and Colitis Organisation (ECCO 2022; 2015), the American College of Gastroenterology (ACG 2021; 2019; 2017; 2010), the World Society of Emergency Surgery (WSES/AAST 2021), the American College of Radiology (ACR 2021), the American Society of Colon and Rectal Surgeons (ASCRS 2021; 2014), and the Healthcare Infection Society (HIS/BSG 2018).
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Guidelines

1.Screening and diagnosis

Clinical presentation: suspect the diagnosis of UC in patients with hematochezia and urgency.
E
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  • Diagnosis

2.Classification and risk stratification

Classification and severity assessment
Categorize disease extent in patients with UC as:
Situation
Guidance
Proctitis
Within 18 cm of the anal verge, distal to the rectosigmoid junction
Left-sided colitis
Extending from the sigmoid to the splenic flexure
Extensive colitis
Beyond the splenic flexure
E
Determine disease severity based on:
Situation
Guidance
Patient-reported outcomes
Bleeding and normalization of bowel habits
Inflammatory burden
Endoscopic assessment including extent and severity
Markers of inflammation
Disease course
Need for hospitalization
Need for corticosteroids
Failure to respond to medications
Disease impact
Functionality
QoL
E

3.Diagnostic investigations

Infectious workup: as per ACG 2021 guidelines, obtain C. difficile testing in patients with IBD presenting with an acute flare associated with diarrhea.
B

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  • Fecal calprotectin

  • Antibody testing

  • Diagnostic imaging

  • Assessment of disease activity

  • Assessment of acute abdomen

  • Evaluation of anemia

  • Screening for osteoporosis

  • Screening for anxiety and depression

4.Diagnostic procedures

Flexible sigmoidoscopy: as per WSES 2021 guidelines, perform sigmoidoscopy for intra-luminal assessment of distal IBD activity, bleeding source identification and biopsies in an acute setting, if available.
B

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  • Lower gastrointestinal endoscopy

5.Medical management

General principles
As per AGA 2020 guidelines:
Use infliximab, adalimumab, golimumab, vedolizumab, tofacitinib, or ustekinumab in adult outpatients with moderate-to-severe UC.
B
Use tofacitinib in adult outpatients with moderate-to-severe UC who are naïve to biologic agents only in the setting of a clinical or registry study.
B

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  • Treatment targets

  • Induction of remission (mild-to-moderate disease)

  • Induction of remission (moderate-to-severe disease)

  • Maintenance of remission (mild-to-moderate disease)

  • Maintenance of remission (moderate-to-severe disease)

  • Maintenance of remission (antibiotics)

  • Management of inadequate treatment response (mild-to-moderate disease)

  • Management of inadequate treatment response (moderate-to-severe disease)

  • Management of acute severe UC

  • Management of acute complications

  • Management of anemia (iron supplementation)

  • Management of anemia (RBC transfusion)

  • Management of anemia (monitoring of recurrence)

  • Management of anemia (management of recurrence)

  • Management of anemia (management of non-IDA anemia)

  • Management of pouchitis (prevention)

  • Management of pouchitis (antibiotics)

  • Management of pouchitis (probiotics)

  • Management of pouchitis (immunosuppressive therapy)

  • Management of pouchitis (mesalamine)

  • Management of pouchitis (fecal microbiota transplantation)

  • Management of pouchitis (management of Crohn's-like disease)

  • Management of pouchitis (management of cuffitis)

6.Inpatient care

Clinical monitoring
Assess all patients with acute severe UC for the presence of toxic megacolon on a regular basis during the hospital admission.
E
Monitor treatment response in all patients with acute severe UC using stool frequency, rectal bleeding, physical examination, vital signs, and serial CRP measurements.
E

7.Nonpharmacologic interventions

Physical activity: encourage endurance training in all patients with IBD. Advise appropriate physical activity (mainly resistance training) in patients with IBD with decreased muscle mass and/or muscle performance.
B

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  • Dietary modifications

  • Nutritional support (counseling)

  • Nutritional support (general principles)

  • Nutritional support (oral nutritional supplements)

  • Nutritional support (enteral nutrition)

  • Nutritional support (parenteral nutrition)

  • Nutritional support (management of malnutrition)

  • Nutritional support (energy requirements)

  • Nutritional support (protein requirements)

  • Nutritional support (micronutrient requirements)

  • Nutritional support (vitamin supplements)

  • Nutritional support (avoidance of dehydration)

  • Nutritional support (avoidance of refeeding syndrome)

  • Probiotics

8.Therapeutic procedures

Fecal microbiota transplantation: as per AGA 2024 guidelines, avoid offering conventional fecal microbiota transplantation in adult patients with UC outside of clinical trials.
D

9.Perioperative care

Preoperative counseling: counsel patients with UC undergoing proctectomy regarding possible effects on fertility, pregnancy, sexual function, and urinary function.
B

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  • Perioperative nutrition

  • Postoperative thromboprophylaxis

10.Surgical interventions

Indications for elective surgery: as per ACG 2019 guidelines, consider elective proctocolectomy in patients with UC failing maximal medical management.
E
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  • Indications for urgent surgery (acute severe UC)

  • Indications for urgent surgery (toxic megacolon)

  • Indications for urgent surgery (uncontrolled bleeding)

  • Indications for urgent surgery (perforation)

  • Indications for urgent surgery (intestinal obstruction)

  • Surgical approach

  • Surgical technique

11.Specific circumstances

Pregnant patients
Monitor iron status and folate levels regularly in pregnant patients with IBD and supplement iron and folic acid in case of deficiencies.
B
Monitor nutritional status regularly in patients with IBD when breastfeeding and supplement in case of deficiencies.
B

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  • Patients with obesity

  • Patients with ostomy

  • Patients with C. difficile infection (antibiotic therapy)

  • Patients with C. difficile infection (withholding immunosuppressive therapy)

  • Patients with C. difficile infection (fecal microbiota transplantation)

12.Preventative measures

Healthy diet: as per AGA 2024 guidelines, recognize that a healthy, balanced, Mediterranean diet rich in a variety of fruits and vegetables and decreased intake of ultra-processed foods are associated with a lower risk of developing IBD.
B

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  • Breastfeeding

  • Routine immunizations

13.Follow-up and surveillance

Follow-up: as per AGA 2023 guidelines, consider using a monitoring strategy combining biomarkers and symptoms in patients with UC in symptomatic remission.
C
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  • CRC surveillance

  • Cervical cancer surveillance

  • Skin cancer surveillance