eMedicine Specialties > Gastroenterology > Colon

Ulcerative Colitis: Differential Diagnoses & Workup

Author: Tri H Le, MD, Assistant Professor of Medicine, Division of Gastroenterology and Hepatology, Penn State Milton S Hershey Medical Center
Contributor Information and Disclosures

Updated: Dec 28, 2009

Differential Diagnoses

Colon Cancer, Adenocarcinoma
Rectal Cancer

Other Problems to Be Considered

Infectious colitis
Ischemic colitis in elderly patients
Radiation colitis
Collagenous colitis and lymphocytic colitis (rarely requires surgery, low risk for malignancy)

Workup

Laboratory Studies

  • Anemia (ie, hemoglobin <14 g/dL in males and <12 g/dL in females)
  • Thrombocytosis (ie, platelet count >350,000/µL)
  • Elevated sedimentation rate (variable reference ranges, usually 0-33 mm/h) and elevated C-reactive protein (ie, >100 mg/L): Both of these findings correlate with disease activity.
  • Hypoalbuminemia (ie, albumin <3.5 g/dL)
  • Hypokalemia (ie, potassium <3.5 mEq/L)
  • Hypomagnesemia (ie, magnesium <1.5 mg/dL)
  • Elevated alkaline phosphatase: More than 125 U/L suggests primary sclerosing cholangitis (usually >3 times the upper limit of the reference range).

Imaging Studies

  • A plain abdominal radiograph might show colonic dilatation in severe cases, suggesting toxic megacolon. Also, evidence of perforation, obstruction, or ileus can be observed.
  • Barium enemas may precipitate toxic megacolon in severe cases. Barium enemas can be performed safely in mild cases. They may show a narrow, tubular, shortened colon with loss of haustral folds, pseudopolyps, and small ulcers.
  • CT scan, in general, plays a minor role in the diagnosis of ulcerative colitis. CT scan can show thickening of the colonic wall. Biliary dilatation suggests primary sclerosing cholangitis.

Other Tests

Procedures

  • Findings on flexible sigmoidoscopy can provide the diagnosis of colitis.
  • Findings on colonoscopy with biopsy confirm a diagnosis (see the image below). Also, this is useful for documenting the extent of the disease, for monitoring disease activity, and for surveillance for dysplasia or cancer; however, be cautious in attempting colonoscopy with biopsy in a patient with severe disease because of the possible risk of perforation or other complications.

    • Ulcerative colitis as visualized with a colonosco...

      Ulcerative colitis as visualized with a colonoscope.

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      Ulcerative colitis as visualized with a colonosco...

      Ulcerative colitis as visualized with a colonoscope.

  • The extent of disease is defined by the following:
    • Extensive disease - Evidence of ulcerative colitis proximal to the splenic flexure
    • Left-sided disease - Ulcerative colitis present in the descending colon up to, but not proximal to, the splenic flexure
    • Proctosigmoiditis - Disease limited to the rectum with or without sigmoid involvement

Histologic Findings

Endoscopically, ulcerative colitis is characterized by a uniform inflammatory reaction limited to the colon by extending from the rectum without intervening areas of normal mucosa to part or all of the colon.

Histologically, most of the pathology is limited to the mucosa and submucosa.  In fulminant cases, the muscularis propria can be affected. Pathologic features that are typically seen include intense infiltration of the mucosa and submucosa with neutrophils and crypt abscesses, lamina propria with lymphoid aggregates, plasma cells, mast cells and eosinophils, and shortening and branching of the crypts. These features are not unique to ulcerative colitis. Except for crypt distortion, the cellular response can be in acute infectious colitis or Crohn disease.

More on Ulcerative Colitis

Overview: Ulcerative Colitis
Differential Diagnoses & Workup: Ulcerative Colitis
Treatment & Medication: Ulcerative Colitis
Follow-up: Ulcerative Colitis
Multimedia: Ulcerative Colitis
References
Further Reading
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References

  1. Jang ES, Lee DH, Kim J, et al. Age as a clinical predictor of relapse after induction therapy in ulcerative colitis. Hepatogastroenterology. Sep-Oct 2009;56(94-95):1304-9. [Medline].

  2. Andersson T, Lunde OC, Johnson E, et al. Long-term functional outcome and quality of life after restorative proctocolectomy with ileo-anal anastomosis for colitis. Colorectal Dis. Dec 14 2009;[Medline].

  3. da Luz Moreira A, Kiran RP, Lavery I. Clinical outcomes of ileorectal anastomosis for ulcerative colitis. Br J Surg. Jan 2010;97(1):65-9. [Medline].

  4. Parente F, Molteni M, Marino B, et al. Are colonoscopy and bowel ultrasound useful for assessing response to short-term therapy and predicting disease outcome of moderate-to-severe forms of ulcerative colitis?: a prospective study. Am J Gastroenterol. Dec 8 2009;[Medline].

  5. Pekow JR, Hetzel JT, Rothe JA, et al. Outcome after surveillance of low-grade and indefinite dysplasia in patients with ulcerative colitis. Inflamm Bowel Dis. Dec 21 2009;[Medline].

  6. Alcalde Encinas MM, Perez-Gracia A, Hallal H, et al. [Cerebral venous sinus thrombosis and ulcerative colitis]. Rev Esp Enferm Dig. Feb 2000;92(2):105-8. [Medline].

  7. Brown MO. Inflammatory bowel disease. Prim Care. Mar 1999;26(1):141-70. [Medline].

  8. Fichera A, Michelassi F. Indication for surgery: a surgeon's opinion. In: Sartor RB, Sandborn WJ. Kirsner's Inflammatory Bowel Diseases. 6th ed. New York: Saunders; 2004:596-601/39.

  9. Froehlich F, Larequi-Lauber T, Gonvers JJ, et al. 11. Appropriateness of colonoscopy: inflammatory bowel disease. Endoscopy. Oct 1999;31(8):647-53. [Medline].

  10. Hanauer SB. Inflammatory bowel disease. N Engl J Med. Mar 28 1996;334(13):841-8. [Medline].

  11. Itzkowitz SH, Present DH. Consensus conference: Colorectal cancer screening and surveillance in inflammatory bowel disease. Inflamm Bowel Dis. Mar 2005;11(3):314-21. [Medline].

  12. Jayanthi V, Probert CS, Mayberry JF. Epidemiology of inflammatory bowel disease. Q J Med. Jan 1991;78(285):5-12. [Medline].

  13. Kamm MA, Sandborn WJ, Gassull M, et al. Once-daily, high-concentration MMX mesalamine in active ulcerative colitis. Gastroenterology. Jan 2007;132(1):66-75; quiz 432-3. [Medline].

  14. Kornbluth A, Sachar DB. Ulcerative colitis practice guidelines in adults (update): American College of Gastroenterology, Practice Parameters Committee. Am J Gastroenterol. Jul 2004;99(7):1371-85. [Medline].

  15. Lichtenstein GR, Abreu MT, Cohen R, et al. American Gastroenterological Association Institute technical review on corticosteroids, immunomodulators, and infliximab in inflammatory bowel disease. Gastroenterology. Mar 2006;130(3):940-87. [Medline].

  16. Rioux JD, Silverberg MS, Daly MJ, et al. Genomewide search in Canadian families with inflammatory bowel disease reveals two novel susceptibility loci. Am J Hum Genet. Jun 2000;66(6):1863-70. [Medline].

  17. Stenson WF, Korzenik J. Inflammatory bowel disease. In: Yamada T, ed. Textbook Of Gastroenterology. Vol 2. 4th ed. Philadephia: Lippincott Williams & Wilkins; 2003:1699-1759.

  18. Thomas GA, Rhodes J, Green JT. Role of smoking in inflammatory bowel disease: implications for therapy. Postgrad Med J. May 2000;76(895):273-9. [Medline].

  19. Tremaine WJ. Collagenous colitis and lymphocytic colitis. J Clin Gastroenterol. Apr 2000;30(3):245-9. [Medline].

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Further Reading

Clinical guidelines:
American Gastroenterological Association Institute medical position statement on corticosteroids, immunomodulators, and infliximab in inflammatory bowel disease. American Gastroenterological Association Institute - Medical Specialty Society. 2006 Mar. 5 pages. NGC:004873

Practice parameters for the surgical treatment of ulcerative colitis. American Society of Colon and Rectal Surgeons - Medical Specialty Society. 1997 (revised 2005 Nov). 13 pages. NGC:005612

Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. American Cancer Society - Disease Specific Society
American College of Radiology - Medical Specialty Society
U.S. Multisociety Task Force on Colorectal Cancer - Medical Specialty Society. 2001 (revised 2008 May-Jun). 31 pages. NGC:007214

Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement. United States Preventive Services Task Force - Independent Expert Panel. 1996 (revised 2008 Oct). 11 pages. NGC:006722

Clinical trials:
Chromoendoscopy for Ulcerative Colitis Surveillance

Immune Regulation in Ulcerative Colitis or Crohn's Disease

Melatonin & Ulcerative Colitis (Melatonin & UC)

Safety and Activity of ORE1001 in Subjects With Ulcerative Colitis

Study of the Safety and Tolerability of ALTH12 Versus Mesalamine Enema in Subjects With Left-Sided Ulcerative Colitis

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Keywords

ulcerative colitis, IBS, colitis, Crohn’s disease, Crohn disease, irritable bowel syndrome, IBD, inflammatory bowel disease, ulcerative colitis treatment, ulcerative colitis symptoms, colonic inflammation, rectal inflammation, toxic megacolon, ileus, diverticulitis, primary sclerosing cholangitis, rectal bleeding, bloody bowel movements

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Contributor Information and Disclosures

Author

Tri H Le, MD, Assistant Professor of Medicine, Division of Gastroenterology and Hepatology, Penn State Milton S Hershey Medical Center
Tri H Le, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, American Society of Gastrointestinal Endoscopy, and Crohns and Colitis Foundation of America
Disclosure: Nothing to disclose.

Medical Editor

Anil Minocha, MD, FACP, FACG, Clinical Professor, School of Pharmacy, Professor of Medicine, Director of Digestive Diseases, Medical Director of Nutrition Support, Medical Director of Gastrointestinal Endoscopy, Internal Medicine Department, University of Mississippi Medical Center
Anil Minocha, MD, FACP, FACG is a member of the following medical societies: American Academy of Clinical Toxicology, American Association for the Study of Liver Diseases, American College of Forensic Examiners, American College of Gastroenterology, American College of Physicians, American Federation for Clinical Research, American Gastroenterological Association, and American Society of Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Noel Williams, MD, Professor Emeritus, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Professor, Department of Internal Medicine, Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
Noel Williams, MD is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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