eMedicine Specialties > Pediatrics: General Medicine > Gastroenterology

Ulcerative Colitis: Follow-up

Author: Jonathan E Markowitz, MD, Associate Professor of Clinical Pediatrics, University of South Carolina School of Medicine; Attending Pediatric Gastroenterologist, Associate Director of Pediatric Residency Program, Greenville Hospital System
Coauthor(s): Petar Mamula, MD, Assistant Professor, Department of Pediatrics, Division of Gastroenterology and Nutrition, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine; Robert Baldassano, MD, Director, Center for Pediatric Inflammatory Bowel Disease, Division of Gastroenterology and Nutrition, Associate Professor, Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania; David A Piccoli, MD, Chief of Pediatric Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia; Professor, University of Pennsylvania School of Medicine; Liz D Dancel, MD, Resident, Department of Pediatrics, Greenville Hospital System University Medical Center
Contributor Information and Disclosures

Updated: Sep 11, 2009

Follow-up

Complications

  • Toxic megacolon is the most serious acute complication of ulcerative colitis (UC) and is reported to occur in up to 5% of patients; it is rare in young patients.
    • Consider toxic megacolon a medical and surgical emergency.
    • The pathogenesis of toxic megacolon is related to severe inflammation resulting in disordered intestinal motility. Disrupted mucosal integrity then may allow bacteria to enter the submucosal tissues, leading to necrosis and peritonitis. Absorptive function is also impaired, resulting in increased luminal fluid volume and electrolyte losses. Toxic megacolon usually occurs in the presence of severe pancolitis. Use of antidiarrheal agents or recent barium enema study or colonoscopy has been implicated as causes of this condition. In addition, metabolic abnormalities (eg, hypokalemia, hypomagnesemia, hypoproteinemia), impaired epithelial integrity of the colon, and altered motor function and are frequently found in patients with toxic megacolon.
    • Toxic megacolon is associated with fever, abdominal distention, and tenderness. Abdominal obstruction series reveals dilatation of the colon with loss of normal haustral markings and signs of edema. Toxic megacolon places the patient at risk for colonic perforation, gram-negative sepsis, and massive hemorrhage.
  • Colonic malignancy is a clinically significant complication in patients with UC.
    • The duration of disease and pancolitis are well-recognized risk factors for malignancy, with the risk of cancer increasing over that of the general population after 10 years. Other less-characterized risk factors include sclerosing cholangitis, a bypassed and defunctionalized segment of bowel, and a low folate level.
    • Children who develop UC before age 14 years have a cumulative colorectal-cancer incidence of 5% at age 20 years and 40% at age 35 years. Patients aged 15-39 years who develop UC have a cumulative incidence of 5% at age 20 years and 30% at age 35 years. The risk for children with onset of disease in the first decade of life is unknown, but these children should undergo colonoscopic screening for dysplasia beginning in adolescence.
    • Epithelial dysplasia generally precedes carcinoma; therefore, perform yearly screening with surveillance colonoscopy and biopsy. Dysplasia can be missed on surveillance biopsy; therefore, consider prophylactic colectomy in adults who developed UC during childhood. With this in mind, psychologically prepare adolescents and young adults by discussing surgical options before the need for surgery arises.
  • Extraintestinal manifestations are common in UC. Approximately 25-35% of patients with inflammatory bowel disease (IBD) have at least one extraintestinal manifestation. Extraintestinal disease may be prognostically important because the rate of pouchitis increases after colectomy in patients with UC and extraintestinal manifestations.
    • Pyoderma gangrenosum occurs in 1% of patients with UC. An indolent chronic ulcer may occur even when disease is in remission. Intralesional therapy with steroids is useful, and colectomy results in healing in approximately one half of patients.
    • Ophthalmologic manifestations most frequently occur when the disease is active. The incidence in adults is 4% but is less in children. The most common findings are episcleritis and anterior uveitis. Uveitis is usually symptomatic, causing pain or decreased vision. Patients with IBD should likely undergo routine ophthalmologic examination.
    • Arthritis is the most common extraintestinal manifestation of IBD, occurring in 10-25% of adolescents. The arthritis is usually a transient, nondeforming synovitis that involves the large joints in an asymmetric distribution. In children, arthritis may precede GI symptoms by years.
    • Hepatobiliary disease is another common extraintestinal manifestation of UC in children. Hepatobiliary complications may precede the onset of GI symptoms, they may accompany active disease, or they may develop after surgical resection. Chronic active hepatitis, granulomatous hepatitis, amyloidosis, fatty liver, and pericholangitis are some of the intrahepatic manifestations of IBD. Extrahepatic manifestations include cholelithiasis and primary sclerosing cholangitis.
    • Thromboembolic disease is considered to be the result of a hypercoagulable state that parallels disease activity and is manifested by thrombocytosis; elevated plasma fibrinogen, factor V, and factor VIII; and decreased plasma antithrombin III. The hypercoagulable state may lead to deep venous thrombosis, pulmonary emboli, and neurovascular disease.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Failure to recognize an infectious etiology (eg, enteric infection, CMV infection, C difficile infection) for colitis
  • Failure to identify disease as Crohn disease (CD) before colectomy
  • Failure to recognize the signs and symptoms of toxic megacolon
  • Failure to recognize signs and symptoms of colonic obstruction
  • Failure to adequately monitor for ophthalmologic complications of the disease or treatment of the disease
  • Failure to screen for dysplasia after several years of disease
  • Failure to seek other forms of treatment after the demonstration of steroid dependence
 


More on Ulcerative Colitis

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

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Further Reading

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Keywords

ulcerative colitis, UC, fulminant colitis, ulcerative proctitis, ulcerative proctocolitis, inflammatory bowel disease, IBD, Crohn disease, Crohn's disease, CD, cryptitis, abdominal cramping, bloody stool, diarrhea, rectal bleeding, anorexia, weight loss, leukocytosis, hypoalbuminemia, severe hemorrhage, toxic megacolon, intestinal perforation, growth failure, arthropathy, tachycardia, tachypnea, anemia, hypokalemia, hypomagnesemia, hypoproteinemia, pancolitis, sclerosing cholangitis, carcinoma, pyoderma gangrenosum, uveitis, arthritis, chronic active hepatitis, granulomatous hepatitis, amyloidosis, fatty liver, pericholangitis, thromboembolic disease, factor V, factor VIII, deep venous thrombosis, pulmonary emboli, neurovascular disease

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Contributor Information and Disclosures

Author

Jonathan E Markowitz, MD, Associate Professor of Clinical Pediatrics, University of South Carolina School of Medicine; Attending Pediatric Gastroenterologist, Associate Director of Pediatric Residency Program, Greenville Hospital System
Jonathan E Markowitz, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, Crohns and Colitis Foundation of America, and North American Society for Pediatric Gastroenterology and Nutrition
Disclosure: Nothing to disclose.

Coauthor(s)

Petar Mamula, MD, Assistant Professor, Department of Pediatrics, Division of Gastroenterology and Nutrition, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine
Petar Mamula, MD is a member of the following medical societies: American Academy of Pediatrics, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, and North American Society for Pediatric Gastroenterology and Nutrition
Disclosure: Nothing to disclose.

Robert Baldassano, MD, Director, Center for Pediatric Inflammatory Bowel Disease, Division of Gastroenterology and Nutrition, Associate Professor, Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania
Robert Baldassano, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Gastroenterological Association, and North American Society for Pediatric Gastroenterology and Nutrition
Disclosure: Nothing to disclose.

David A Piccoli, MD, Chief of Pediatric Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia; Professor, University of Pennsylvania School of Medicine
David A Piccoli, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American Gastroenterological Association, and North American Society for Pediatric Gastroenterology and Nutrition
Disclosure: Nothing to disclose.

Liz D Dancel, MD, Resident, Department of Pediatrics, Greenville Hospital System University Medical Center
Disclosure: Nothing to disclose.

Medical Editor

Jorge H Vargas, MD, Professor of Pediatrics and Clinical Professor of Pediatric Gastroenterology, David Geffen School of Medicine, University of California at Los Angeles; Consulting Physician, Department of Pediatrics, University of California at Los Angeles Health System
Jorge H Vargas, MD is a member of the following medical societies: American Liver Foundation, American Society for Gastrointestinal Endoscopy, American Society for Parenteral and Enteral Nutrition, Latin American Society of Pediatric Gastroenterology, Hepatology & Nutrition, and North American Society for Pediatric Gastroenterology and Nutrition
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

David A Piccoli, MD, Chief of Pediatric Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia; Professor, University of Pennsylvania School of Medicine
David A Piccoli, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American Gastroenterological Association, and North American Society for Pediatric Gastroenterology and Nutrition
Disclosure: Nothing to disclose.

CME Editor

Steven M Schwarz, MD, FAAP, FACN, AGAF, Professor of Pediatrics, Children's Hospital at Downstate, SUNY-Downstate Medical Center
Steven M Schwarz, MD, FAAP, FACN, AGAF is a member of the following medical societies: American Academy of Pediatrics, American College of Nutrition, American College of Physician Executives, American Gastroenterological Association, American Pediatric Society, Gastroenterology Research Group, New York Academy of Medicine, North American Society for Pediatric Gastroenterology and Nutrition, and Society for Pediatric Research
Disclosure: TAP Pharmaceuticals Honoraria Speaking and teaching; Curemark, LLC Consulting fee Board membership; Centocor, Inc. Grant/research funds Independent contractor

Chief Editor

Carmen Cuffari, MD, Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine
Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

 
 
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