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A 24-year-old male presents to his primary care physician with complaint of bloody diarrhea x 1 week. Preceding this, he had generalized abdominal cramping and increased frequency of stools for two weeks. He also complains of fatigue and a five-pound unintentional weight loss. He denies fever or chills. He has no known ill contacts. On physical examination, he has mild tenderness to palpation in the left lower abdomen. Labs are notable for iron deficiency anemia (iron = 16 ug/mL, ferritin = 6 ng/mL, hemoglobin = 8.3 g/dL), leukocytosis (WBC = 20,000) and elevated C-reactive protein (CRP = 152 mg/dL). Stool studies were completed and negative for infectious diarrhea. He was referred to the GI office for further evaluation.

Flexible sigmoidoscopy was performed showing marked erythema, loss of vascular pattern, friability and erosions in the sigmoid colon and rectum. Sigmoid biopsies showed severe active chronic colitis with ulceration and crypt abscess formation.

What is the most likely diagnosis?

A) Crohn’s disease
B) Microscopic colitis
C) Ischemic colitis
D) Infectious colitis
E) Ulcerative colitis

The correct answer is E, ulcerative colitis (UC). This patient has severe left-sided ulcerative colitis (ulcerative proctosigmoiditis) with iron deficiency anemia.

Practice Pearls

Clinical Presentation

• Patients with UC often present with diarrhea. Associated symptoms include hematochezia, tenesmus and fecal incontinence.^1,2,3
• Symptoms are often progressive and may be accompanied by abdominal cramping, fever, fatigue and weight loss.²
• Physical examination may be normal in patients with mild to moderate disease. In patients with severe UC, patients may have abdominal tenderness, fever, hypotension and tachycardia.^1,2
• Extraintestinal manifestations of UC include arthropathy, uveitis, episcleritis, PSC and autoimmune liver disease.^1,2,3

Diagnosis

• Labs may show iron deficiency anemia, elevated erythrocyte sedimentation rate, low albumin, elevated CRP and electrolyte abnormalities (from diarrhea/dehydration). Fecal calprotectin may also be elevated.^1,2
• Abdominal imaging is not required for the diagnosis of UC.²
• Endoscopic findings (Figure 1) show loss of vascularity, erythema, granularity of mucosa, friability and sometimes bleeding. Inflammation involves the rectum and extends proximally in a contiguous pattern.^1,2,3
• Histologic features in UC^2,3
  • Crypt abscesses, crypt branching, crypt atrophy
  • Epithelial cell abnormalities (mucin depletion, Paneth cell metaplasia)
  • Inflammatory changes (lamina propria cellularity, basal plasmacytosis, basal lymphoid aggregates, lamina propria eosinophils)

Figure 1: Inflamed mucosa in the rectum and sigmoid colon

Photo courtesy of Sarah Enslin, PA-C.

Treatment

• Mild to moderate disease²
  • Induce remission
    • Topical mesalamine
    • Topical glucocorticoids
    • Oral 5-ASA
    • Oral glucocorticoids
  • Maintenance therapy
    • Topical mesalamine
    • Oral 5-ASA
• Moderate to severe disease^1,2
  • Anti-tumor necrosis factor therapy (infliximab, adalimumab, golimumab) with or without immunomodulator (azathioprine, mercaptopurine)
  • Anti-integrin antibody (vedolizumab)
  • Anti-interleukin 12/23 antibody (ustekinumab)
  • Systemic glucocorticoids
  • JAK inhibitors (tofacitinib, upadacitinib)
  • Oral sphingosine-1-phosphate receptor modulator (ozanimod)
  • Intravenous glucocorticoids  

• Authors
• References