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Diagnosis of Ulcerative Colitis

The diagnosis of ulcerative colitis is clinical and based on the combination of the clinical presentation, mucosal appearance at endoscopy or radiography, and histologic findings in mucosal biopsies.

The laboratory features of ulcerative colitis are nonspecific and reflect the severity of inflammation (i.e., increased erythrocyte sedimentation rate, leukocytosis with a “left shift”), complications of diarrhea (hypokalemia, alkalosis, other electrolyte disturbances), or complications of mucosal exudation (anemia from chronic blood loss and iron deficiency or hypoalbuminemia from protein exudation).

Recently, serologic tests have been evaluated for sensitivity and specificity in IBD. In ulcerative colitis there is a unique perinuclear antineutrophil cytoplasmic antibody (pANCA) that is present in approx 60% of confirmed cases. The specificity of pANCA is only approx 80% for UC. In contrast anti-Saccharomyces cerevisiae antibodies (ASCA) are more common in patients with CD. The combination of a positive pANCA Chapter 5 / Diagnosis of IBD 81 and a negative ASCA supports, but does not confirm, the clinical diagnosis of UC. However, because of their limited sensitivity and specificity, these serologic tests do not generally alter the clinical impression as to the presence or absence of IBD.

A hallmark of active colitis is the presence of fecal leukocytes on wet mount. Additional stool studies are necessary to rule out infectious colitis due to bacteria [including Clostridium difficile and enterohemorrhagic E. coli (E.coli O157:H7)] or parasites (especially amebiasis).

Plain abdominal radiography is mostly useful in excluding perforation or megacolon. Rarely, CT scans are used to rule out an abdominal abscess. However, for the most part, while air-contrast barium enemas can be used to confirm mucosal inflammation in UC, these studies have been supplanted by endoscopic examinations with flexible sigmoidoscopes or colonoscopes. Colonoscopy, including examination into the terminal ileum, is eventually performed in all patients to assess the extent of involvement, obtain biopsies and rule out ileitis. However, in the acute setting, flexible sigmoidoscopy is sufficient to assess severity and extent beyond proctosigmoiditis, and to obtain biopsies. Careful sigmoidoscopy is safe in patients with severe disease. The inflammatory changes are nearly always more severe distally, and range from mild (erythema, loss of vascular pattern and granularity), to moderate (friability, petechiae, nonconfluent ulcerations), or severe (confluent ulcerations, mucopus, spontaneous hemorrhage). Additional findings may include the presence of postinflammatory pseudopolyps.

Mucosal biopsies reflect the diffuse, continuous, superficial inflammation with acute and chronic inflammatory cells, cryptitis, and crypt abscesses. These changes are nonspecific and may be difficult to distinguish from changes secondary to infection. In contrast, distortion of intestinal crypts (irregular, elongated, or branched crypts) is a hallmark of idiopathic IBD and persists, not only in active ulcerative colitis (or CD) but also in quiescent UC. The diffuse, superficial mucosal changes in UC differentiate it from CD, where focal and transmural inflammation is more common. The colonic mucosa proximal to the demarcating margin of colitis is normal.