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SOURCE

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Source: Hemstreet BA. Inflammatory bowel disease. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 10th ed. New York, NY: McGraw-Hill; 2017. http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861&sectionid=146059124. Accessed May 16, 2017.

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DEFINITION

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  • Idiopathic inflammatory bowel disease (IBD) manifesting as mucosal inflammation confined to rectum and colon.

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ETIOLOGY

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  • Unknown, but major theories include combination of infectious, genetic, and immunologic causes.

    • Infectious.

      • Viruses.

      • Protozoa.

      • Mycobacteria (eg, Mycobacterium paratuberculosis or avium)

      • Listeria monocytogenes

      • Chlamydia trachomatis

      • Escherichia coli

      • Ruminococcus gnavus or torques

    • Genetics.

      • Gene defects.

        • Genes encoding the IL-10 and the IL-10 receptor.

    • Immune.

      • Immune-mediated mucosal damage.

      • Dysregulation of cytokines.

    • Lifestyle.

      • Smoking appears to be protective for UC

    • Diet.

      • Increased protein intake.

      • Vitamin D deficiency.

    • Drugs.

      • Nonsteroidal anti-inflammatory drugs (NSAIDs)

      • Oral contraceptives.

      • Isotretinoin.

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PATHOPHYSIOLOGY

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  • Inflammation of mucosa and submucosa of rectum and colon.

  • Extensive mucosal damage.

  • Complications – Local.

    • Hemorrhoids.

    • Anal fissures.

    • Perirectal abscesses.

    • Toxic megacolon.

      • Major complication.

      • Severe condition that occurs in up to 7.9% of UC patients admitted to hospitals.

      • Symptoms:

        • High fever.

        • Tachycardia.

        • Distended abdomen.

        • Elevated white blood cell count.

        • Dilated colon.

    • Colonic perforation.

    • Colonic hemorrhage.

    • Colon cancer.

      • Increased risk as compared to general population.

      • Risk increases as length of UC history increases.

  • Complications – Systemic.

    • Hepatobiliary.

      • Occur in approximately 11% of patients with UC

        • Fatty liver.

        • Pericholangitis.

        • Chronic active hepatitis.

        • Cirrhosis.

        • Sclerosing cholangitis.

        • Cholangiocarcinoma.

        • Gallstones.

    • Arthritis.

      • Asymmetric and migratory.

    • Ocular.

      • Occur in approximately 10% of patients with UC

        • Iritis.

        • Uveitis.

        • Episcleritis.

        • Conjunctivitis.

    • Dermatologic and mucosal.

      • Occur in 5–10% of patients with UC

        • Erythema nodosum.

        • Pyoderma gangrenosum.

        • Aphthous stomatitis.

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CLINICAL PRESENTATION

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  • Highly variable.

    • Intermittent bouts of illness after varying intervals of no symptoms commonly seen.

  • Presentation (Table 1)

    • Mild abdominal cramping with frequent small-volume bowel movements to profuse diarrhea.

  • Disease classification.

    • Mild (two-thirds of patients)

      • Fewer than 4 stools daily.

      • With or without blood.

      • No systemic disturbance.

      • Normal erythrocyte sedimentation rate (ESR)

    • Moderate.

      • More than 4 stools per day.

      • Minimal systemic disturbance.

    • Severe.

      • More than 6 stools per day with blood.

      • Evidence of systemic disturbance as shown by:

        • Fever.

        • Tachycardia.

        • Anemia.

        • ESR >30

    • Fulminant.

      • More than 10 stools per day with continuous bleeding.

        • Transfusions required.

      • Toxicity.

      • Abdominal tenderness.

      • Colonic dilation.

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Table Graphic Jump Location
TABLE 1.Clinical Presentation of Ulcerative Colitis

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