Case history
This 55 year old recently redundant steelworker was admitted on an acute take at a local teaching hospital. This was one of many such admissions to hospital over previous years with similar complaints. His main complaints were of lower abdominal pain, weight loss of approximately 7 kg over the past month, and diarrhoea. He had been passing five loose motions a day, including one at night, which on many occasions had contained blood. On examination he is found to be tender in the left iliac fossa and a per rectum examination reveals blood. You also note raised, red nodules on his shins that he says are painful and have been present for the past three weeks. He has an eight year history of "arthritis."

Given the consultant's knowledge of this man's history a barium enema was undertaken the following day. A section of the large bowel is shown on the film.

Questions

(1) What abnormal radiological features can be seen on this film?

(2) What is your differential diagnosis given the clinical history and radiological findings?

(3) What else could you do to help your diagnosis and what are you likely to find?

(4) What extraintestinal manifestations of this disease do you know?

(5) What radical procedure could be undertaken to eliminate all symptoms?

Answers

(1) The normal sharp mucosal pattern is lost, and the rectosigmoidal mucosa seem fuzzy. This is the result of ulceration within the abnormal section of the rectosigmoid colon. The appearances reflect small quantities of the contrast, which deposit within these ulcerated mucosal clefts. These clefts are sometimes called "collar button ulcers."

Compare the sigmoid with the normal smooth, sharp caecal and right colonic mucosal pattern seen on this film in the right upper quadrant of the image.

In ulcerative colitis, the disease begins in the rectum with the proximal colitis continuous and symmetrical in nature. (This helps to differentiate it from Crohn's disease, which is classically asymmetrical and discontinuous.)

The main radiological signs of chronic disease are (not seen on this film):

* Foreshortening of the colon.

* Loss of the normal haustral pattern.

* A narrowed and tubular colon (also known as "stovepipe," "garden hose," or "drainpipe" colon).

* Polyps. There are three types--pseudopolyps: usually in acute attacks; inflammatory: usually with low grade inflammation; and filiform: seen on the back of normal mucosa. This may be the only evidence of previous inflammation.

We should mention toxic megacolon, which is an important complication of acute ulcerative colitis. Toxic megacolon usually occurs during a florid, acute exacerbation. Radiological diagnosis is made by observing a widened transverse colon (greater than 6.5 cm), with inflamed mucosa and "thumbprinting," on a plain film. Barium enema is contraindicated in this condition due to the high risk of perforation and faecal peritonitis.

(2) Ulcerative colitis, pseudomembranous colitis, ischaemic colitis, Crohn's disease.

The likely diagnosis is ulcerative colitis, which is a recurrent, inflammatory large bowel disease.

(3) A colonoscopy, with multiple biopsies of the abnormal areas, to ascertain the exact diagnosis. The microscopic features of ulcerative colitis are distinct. These are:

* Inflammation and ulceration confined to the mucosal and submucosal layers only.

* Presence of crypt abscesses.

* Inflammatory pseudopolyps.

* Loss of goblet cells.

(4) There are several manifestations that include erythema nodosum, pyoderma gangrenosum, cholangiocarcinoma, primary sclerosing cholangitis, amyloi dosis, ankylosing spondylitis, seronegative spondylarthritides, ophthalmic complaints (uveitis, scleritis, conjunctivitis), thrombosis, and embolism.

It is worth noting that there is an increased chance of colorectal carcinoma in patients with longstanding ulcerative colitis. Those with extensive colitis for more than seven years are usually enrolled in an annual surveillance programme entailing colonoscopy and multiple biopsies.

(5) A panproctocolectomy (removal of the whole large bowel) with formation of an ileostomy (a spout of ileum to form an artificial opening, usually in the right iliac fossa). Some, chiefly younger patients, may opt for a pouch operation whereby the terminal ileum is used to fashion a "new" rectum that is then anastamosed with the anus, thus avoiding a stoma.

As this is an inflammatory disease distinct to the large bowel (unlike Crohn's disease that can affect the whole gastrointestinal tract) its removal will eradicate the disease. If all medical management has failed or there are complications with severe ulcerative colitis this is a surgical option.