Clin Colon Rectal Surg 2022; 35(06): 421-427
DOI: 10.1055/s-0042-1758047
Review Article

Diagnosis and Monitoring of Ulcerative Colitis

Megan E. Murphy
1   Division of Gastroenterology, Department of Medicine, Inflammatory Bowel Disease Center at NYU Langone Health, NYU Grossman School of Medicine, New York, New York
,
Sumona Bhattacharya
1   Division of Gastroenterology, Department of Medicine, Inflammatory Bowel Disease Center at NYU Langone Health, NYU Grossman School of Medicine, New York, New York
,
Jordan E. Axelrad
1   Division of Gastroenterology, Department of Medicine, Inflammatory Bowel Disease Center at NYU Langone Health, NYU Grossman School of Medicine, New York, New York
› Author Affiliations

Abstract

Ulcerative colitis is one of the two main subtypes of inflammatory bowel disease, along with Crohn's disease. Understanding the clinical and endoscopic features of ulcerative colitis is critical in achieving a timely diagnosis. An initial evaluation includes assessing clinical symptoms, inflammatory markers, endoscopic findings, and determination of the presence or absence of extraintestinal manifestations. Initial disease management should consider disease severity at the time of diagnosis as well as prognostication, or the determination of risk factors present with a high likelihood of severe disease in the future. Once appropriate therapy has been initiated, ongoing monitoring is crucial, which may include repeated clinical assessments over time, measuring noninvasive markers of inflammation, and endoscopic and histologic reevaluation. An important aspect of disease monitoring in ulcerative colitis is dysplasia surveillance; there are many patient-specific risk factors which influence surveillance strategies. Utilizing appropriate surveillance techniques is necessary for early detection of dysplasia and colorectal neoplasia.



Publication History

Article published online:
28 October 2022

© 2022. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 
  • References

  • 1 Magro F, Gionchetti P, Eliakim R. et al; European Crohn's and Colitis Organisation [ECCO]. Third European evidence-based consensus on diagnosis and management of ulcerative colitis. Part 1: definitions, diagnosis, extra-intestinal manifestations, pregnancy, cancer surveillance, surgery, and ileo-anal pouch disorders. J Crohn's Colitis 2017; 11 (06) 649-670
  • 2 Fumery M, Singh S, Dulai PS, Gower-Rousseau C, Peyrin-Biroulet L, Sandborn WJ. Natural history of adult ulcerative colitis in population-based cohorts: a systematic review. Clin Gastroenterol Hepatol 2018; 16 (03) 343-356.e3
  • 3 Meyers S, Janowitz HD. The “natural history” of ulcerative colitis: an analysis of the placebo response. J Clin Gastroenterol 1989; 11 (01) 33-37
  • 4 Stange EF, Travis SPL, Vermeire S. et al; European Crohn's and Colitis Organisation (ECCO). European evidence-based Consensus on the diagnosis and management of ulcerative colitis: definitions and diagnosis. J Crohn's Colitis 2008; 2 (01) 1-23
  • 5 Danese S, Fiocchi C. Ulcerative colitis. N Engl J Med 2011 Nov 3;365(18):1713–25. Doi: 10.1056/NEJMra1102942. PMID: 22047562
  • 6 Rubin DT, Ananthakrishnan AN, Siegel CA, Sauer BG, Long MD. ACG clinical guideline: ulcerative colitis in adults. Am J Gastroenterol 2019; 114 (03) 384-413
  • 7 Dassopoulos T, Cohen RD, Scherl EJ, Schwartz RM, Kosinski L, Regueiro MD. Ulcerative colitis care pathway. Gastroenterology 2015; 149 (01) 238-245
  • 8 Rao SSC, Holdsworth CD, Read NW. Symptoms and stool patterns in patients with ulcerative colitis. Gut 1988; 29 (03) 342-345
  • 9 Mahid SS, Minor KS, Soto RE, Hornung CA, Galandiuk S. Smoking and inflammatory bowel disease: a meta-analysis. Mayo Clin Proc 2006; 81 (11) 1462-1471
  • 10 Takeuchi K, Smale S, Premchand P. et al. Prevalence and mechanism of nonsteroidal anti-inflammatory drug-induced clinical relapse in patients with inflammatory bowel disease. Clin Gastroenterol Hepatol 2006; 4 (02) 196-202
  • 11 Singh S, Graff LA, Bernstein CN. Do NSAIDs, antibiotics, infections, or stress trigger flares in IBD?. Am J Gastroenterol 2009; 104 (05) 1298-1313 , quiz 1314
  • 12 Yoon JY, Park SJ, Hong SP, Kim TI, Kim WH, Cheon JH. Correlations of C-reactive protein levels and erythrocyte sedimentation rates with endoscopic activity indices in patients with ulcerative colitis. Dig Dis Sci 2014; 59 (04) 829-837
  • 13 Solberg IC, Høivik ML, Cvancarova M, Moum B. IBSEN Study Group. Risk matrix model for prediction of colectomy in a population-based study of ulcerative colitis patients (the IBSEN study). Scand J Gastroenterol 2015; 50 (12) 1456-1462
  • 14 Travis SPL, Farrant JM, Ricketts C. et al. Predicting outcome in severe ulcerative colitis. Gut 1996; 38 (06) 905-910
  • 15 Mosli MH, Zou G, Garg SK. et al. C-reactive protein, fecal calprotectin, and stool lactoferrin for detection of endoscopic activity in symptomatic inflammatory bowel disease patients: a systematic review and meta-analysis. Am J Gastroenterol 2015; 110 (06) 802-819 , quiz 820
  • 16 Turner D, Ricciuto A, Lewis A. et al; International Organization for the Study of IBD. STRIDE-II: an update on the Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) initiative of the International Organization for the Study of IBD (IOIBD): determining therapeutic goals for treat-to-target strategies in IBD. Gastroenterology 2021; 160 (05) 1570-1583
  • 17 Sands BE. Biomarkers of inflammation in inflammatory bowel disease. Gastroenterology 2015; 149 (05) 1275-1285.e2
  • 18 Turvill J, O'Connell S, Brooks A. et al. Evaluation of a faecal calprotectin care pathway for use in primary care. Prim Health Care Res Dev 2016; 17 (05) 428-436
  • 19 Grant RK, Jones GR, Plevris N. et al. The ACE (albumin, CRP and endoscopy) index in acute colitis: a simple clinical index on admission that predicts outcome in patients with acute ulcerative colitis. Inflamm Bowel Dis 2021; 27 (04) 451-457
  • 20 Plevy S, Silverberg MS, Lockton S. et al. Combined serological, genetic, and inflammatory markers differentiate non-IBD, Crohn's disease, and ulcerative colitis patients. Inflamm Bowel Dis 2013; 19 (06) 1139-1148
  • 21 Kevans D, Waterman M, Milgrom R, Xu W, Van Assche G, Silverberg M. Serological markers associated with disease behavior and response to anti-tumor necrosis factor therapy in ulcerative colitis. J Gastroenterol Hepatol 2015; 30 (01) 64-70
  • 22 Hourigan SK, Oliva-Hemker M, Hutfless S. The prevalence of Clostridium difficile infection in pediatric and adult patients with inflammatory bowel disease. Dig Dis Sci 2014; 59 (09) 2222-2227
  • 23 Nguyen GC, Kaplan GG, Harris ML, Brant SR. A national survey of the prevalence and impact of Clostridium difficile infection among hospitalized inflammatory bowel disease patients. Am J Gastroenterol 2008; 103 (06) 1443-1450
  • 24 Issa M, Vijayapal A, Graham MB. et al. Impact of Clostridium difficile on inflammatory bowel disease. Clin Gastroenterol Hepatol 2007; 5 (03) 345-351
  • 25 Feuerstein JD, Isaacs KL, Schneider Y, Siddique SM, Falck-Ytter Y, Singh S. AGA Institute Clinical Guidelines Committee. AGA clinical practice guidelines on the management of moderate to severe ulcerative colitis. Gastroenterology 2020; 158 (05) 1450-1461
  • 26 Binder SC, Patterson JF, Glotzer DJ. Toxic megacolon in ulcerative colitis. Gastroenterology 1974; 66 (05) 909-915
  • 27 Kilcoyne A, Kaplan JL, Gee MS. Inflammatory bowel disease imaging: current practice and future directions. World J Gastroenterol 2016; 22 (03) 917-932
  • 28 Shergill AK, Lightdale JR, Bruining DH. et al; American Society for Gastrointestinal Endoscopy Standards of Practice Committee. The role of endoscopy in inflammatory bowel disease. Gastrointest Endosc 2015; 81 (05) 1101-21.e1 , 13
  • 29 Silverberg MS, Satsangi J, Ahmad T. et al. Toward an integrated clinical, molecular and serological classification of inflammatory bowel disease: report of a Working Party of the 2005 Montreal World Congress of Gastroenterology. Can J Gastroenterol 2005; 19 (Suppl A): 5A-36A
  • 30 Satsangi J, Silverberg MS, Vermeire S, Colombel JF. The Montreal classification of inflammatory bowel disease: controversies, consensus, and implications. Gut 2006; 55 (06) 749-753
  • 31 Park SH, Yang SK, Park SK. et al. Atypical distribution of inflammation in newly diagnosed ulcerative colitis is not rare. Can J Gastroenterol Hepatol 2014; 28 (03) 125-130
  • 32 Choi YS, Kim JK, Kim WJ. Clinical characteristics and prognosis of patients with ulcerative colitis that shows rectal sparing at initial diagnosis. World J Gastrointest Endosc 2021; 13 (09) 407-415
  • 33 Horio Y, Uchino M, Bando T. et al. Rectal-sparing type of ulcerative colitis predicts lack of response to pharmacotherapies. BMC Surg 2017; 17 (01) 59
  • 34 Oshitani N, Kitano A, Nakamura S. et al. Clinical and prognostic features of rectal sparing in ulcerative colitis. Digestion 1989; 42 (01) 39-43
  • 35 Glickman JN, Bousvaros A, Farraye FA. et al. Pediatric patients with untreated ulcerative colitis may present initially with unusual morphologic findings. Am J Surg Pathol 2004; 28 (02) 190-197
  • 36 DeRoche TC, Xiao SY, Liu X. Histological evaluation in ulcerative colitis. Gastroenterol Rep (Oxf) 2014; 2 (03) 178-192
  • 37 Robert ME, Skacel M, Ullman T, Bernstein CN, Easley K, Goldblum JR. Patterns of colonic involvement at initial presentation in ulcerative colitis: a retrospective study of 46 newly diagnosed cases. Am J Clin Pathol 2004; 122 (01) 94-99
  • 38 Theodoropoulou A, Koutroubakis IE. Ischemic colitis: clinical practice in diagnosis and treatment. World J Gastroenterol 2008; 14 (48) 7302-7308
  • 39 Truelove SC, Witts LJ. Cortisone in ulcerative colitis; final report on a therapeutic trial. BMJ 1955; 2 (4947): 1041-1048
  • 40 Schroeder KW, Tremaine WJ, Ilstrup DM. Coated oral 5-aminosalicylic acid therapy for mildly to moderately active ulcerative colitis. A randomized study. N Engl J Med 1987; 317 (26) 1625-1629
  • 41 Walmsley RS, Ayres RC, Pounder RE, Allan RN. A Simple Clinical Colitis Activity Index. Gut 1998; 43 (01) 29-32
  • 42 Seo M, Okada M, Yao T, Ueki M, Arima S, Okumura M. An index of disease activity in patients with ulcerative colitis. Am J Gastroenterol 1992; 87 (08) 971-976
  • 43 Walsh AJ, Ghosh A, Brain AO. et al. Comparing disease activity indices in ulcerative colitis. J Crohn's Colitis 2014; 8 (04) 318-325
  • 44 Pera A, Bellando P, Caldera D. et al. Colonoscopy in inflammatory bowel disease. Diagnostic accuracy and proposal of an endoscopic score. Gastroenterology 1987; 92 (01) 181-185
  • 45 Bousvaros A, Antonioli DA, Colletti RB. et al; North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition, Colitis Foundation of America. Differentiating ulcerative colitis from Crohn disease in children and young adults: report of a working group of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the Crohn's and Colitis Foundation of America. J Pediatr Gastroenterol Nutr 2007; 44 (05) 653-674
  • 46 Heresbach D, Alexandre JL, Branger B. et al; ABERMAD (Association Bretonne d'Etude et de Recherche sur les Maladies de l'Appareil Digestif). Frequency and significance of granulomas in a cohort of incident cases of Crohn's disease. Gut 2005; 54 (02) 215-222
  • 47 Rubio CA, Orrego A, Nesi G, Finkel Y. Frequency of epithelioid granulomas in colonoscopic biopsy specimens from paediatric and adult patients with Crohn's colitis. J Clin Pathol 2007; 60 (11) 1268-1272
  • 48 Goldstein N, Dulai M. Contemporary morphologic definition of backwash ileitis in ulcerative colitis and features that distinguish it from Crohn disease. Am J Clin Pathol 2006; 126 (03) 365-376
  • 49 Solberg IC, Lygren I, Jahnsen J. et al; IBSEN Study Group. Clinical course during the first 10 years of ulcerative colitis: results from a population-based inception cohort (IBSEN Study). Scand J Gastroenterol 2009; 44 (04) 431-440
  • 50 Hoie O, Wolters FL, Riis L. et al; European Collaborative Study Group of Inflammatory Bowel Disease. Low colectomy rates in ulcerative colitis in an unselected European cohort followed for 10 years. Gastroenterology 2007; 132 (02) 507-515
  • 51 Monstad I, Hovde O, Solberg ICA. A Moum B, Clinical course and prognosis in ulcerative colitis: results from population-based and observational studies. Ann Gastroenterol 2014; 27 (02) 95-104
  • 52 Høivik ML, Reinisch W, Cvancarova M, Moum B. IBSEN study group. Anaemia in inflammatory bowel disease: a population-based 10-year follow-up. Aliment Pharmacol Ther 2014; 39 (01) 69-76
  • 53 Sjöberg D, Holmström T, Larsson M, Nielsen AL, Holmquist L, Rönnblom A. Anemia in a population-based IBD cohort (ICURE): still high prevalence after 1 year, especially among pediatric patients. Inflamm Bowel Dis 2014; 20 (12) 2266-2270
  • 54 Wells CW, Lewis S, Barton JR, Corbett S. Effects of changes in hemoglobin level on quality of life and cognitive function in inflammatory bowel disease patients. Inflamm Bowel Dis 2006; 12 (02) 123-130
  • 55 Murthy SK, Nguyen GC. Venous thromboembolism in inflammatory bowel disease: an epidemiological review. Am J Gastroenterol 2011; 106 (04) 713-718
  • 56 Bernstein CN, Nugent Z, Singh H. Persistently high rate of venous thromboembolic disease in inflammatory bowel disease: a population-based study. Am J Gastroenterol 2021; 116 (07) 1476-1484
  • 57 Rogler G, Singh A, Kavanaugh A, Rubin DT. Extraintestinal manifestations of inflammatory bowel disease: current concepts, treatment, and implications for disease management. Gastroenterology 2021; 161 (04) 1118-1132
  • 58 Vavricka SR, Brun L, Ballabeni P. et al. Frequency and risk factors for extraintestinal manifestations in the Swiss inflammatory bowel disease cohort. Am J Gastroenterol 2011; 106 (01) 110-119
  • 59 Vavricka SR, Schoepfer A, Scharl M, Lakatos PL, Navarini A, Rogler G. Extraintestinal manifestations of inflammatory bowel disease. Inflamm Bowel Dis 2015; 21 (08) 1982-1992
  • 60 Farhi D, Cosnes J, Zizi N. et al. Significance of erythema nodosum and pyoderma gangrenosum in inflammatory bowel diseases: a cohort study of 2402 patients. Medicine (Baltimore) 2008; 87 (05) 281-293
  • 61 Taleban S, Li D, Targan SR. et al. Ocular manifestations in inflammatory bowel disease are associated with other extra-intestinal manifestations, gender, and genes implicated in other immune-related traits. J Crohn's Colitis 2016; 10 (01) 43-49
  • 62 Fraga M, Fournier N, Safroneeva E. et al; Swiss IBD Cohort Study Group. Primary sclerosing cholangitis in the Swiss Inflammatory Bowel Disease Cohort Study: prevalence, risk factors, and long-term follow-up. Eur J Gastroenterol Hepatol 2017; 29 (01) 91-97
  • 63 Bryant RV, Burger DC, Delo J. et al. Beyond endoscopic mucosal healing in UC: histological remission better predicts corticosteroid use and hospitalisation over 6 years of follow-up. Gut 2016; 65 (03) 408-414
  • 64 Christensen B, Hanauer SB, Erlich J. et al. Histologic normalization occurs in ulcerative colitis and is associated with improved clinical outcomes. Clin Gastroenterol Hepatol 2017; 15 (10) 1557-1564.e1
  • 65 Shah SC, Colombel JF, Sands BE, Narula N. Mucosal healing is associated with improved long-term outcomes of patients with ulcerative colitis: a systematic review and meta-analysis. Clin Gastroenterol Hepatol 2016; 14 (09) 1245-1255.e8
  • 66 Ardizzone S, Cassinotti A, Duca P. et al. Mucosal healing predicts late outcomes after the first course of corticosteroids for newly diagnosed ulcerative colitis. Clin Gastroenterol Hepatol 2011; 9 (06) 483-489.e3
  • 67 Colombel JF, Rutgeerts P, Reinisch W. et al. Early mucosal healing with infliximab is associated with improved long-term clinical outcomes in ulcerative colitis. Gastroenterology 2011; 141 (04) 1194-1201
  • 68 Frøslie KF, Jahnsen J, Moum BA, Vatn MH. IBSEN Group. Mucosal healing in inflammatory bowel disease: results from a Norwegian population-based cohort. Gastroenterology 2007; 133 (02) 412-422
  • 69 Jangi S, Holmer AK, Dulai PS. et al. Risk of relapse in patients with ulcerative colitis with persistent endoscopic healing: a durable treatment endpoint. J Crohn's Colitis 2021; 15 (04) 567-574
  • 70 Baars JE, Nuij VJAA, Oldenburg B, Kuipers EJ, van der Woude CJ. Majority of patients with inflammatory bowel disease in clinical remission have mucosal inflammation. Inflamm Bowel Dis 2012; 18 (09) 1634-1640
  • 71 D'Haens G, Ferrante M, Vermeire S. et al. Fecal calprotectin is a surrogate marker for endoscopic lesions in inflammatory bowel disease. Inflamm Bowel Dis 2012; 18 (12) 2218-2224
  • 72 Lin JF, Chen JM, Zuo JH. et al. Meta-analysis: fecal calprotectin for assessment of inflammatory bowel disease activity. Inflamm Bowel Dis 2014; 20 (08) 1407-1415
  • 73 Zittan E, Kelly OB, Kirsch R. et al. Low fecal calprotectin correlates with histological remission and mucosal healing in ulcerative colitis and colonic Crohn's disease. Inflamm Bowel Dis 2016; 22 (03) 623-630
  • 74 Travis SPL, Schnell D, Krzeski P. et al. Reliability and initial validation of the Ulcerative Colitis Endoscopic Index of Severity. Gastroenterology 2013; 145 (05) 987-995
  • 75 Travis SPL, Schnell D, Krzeski P. et al. Developing an instrument to assess the endoscopic severity of ulcerative colitis: the Ulcerative Colitis Endoscopic Index of Severity (UCEIS). Gut 2012; 61 (04) 535-542
  • 76 Peyrin-Biroulet L, Sandborn W, Sands BE. et al. Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE): determining therapeutic goals for treat-to-target. Am J Gastroenterol 2015; 110 (09) 1324-1338
  • 77 Allocca M, Danese S, Laurent V, Peyrin-Biroulet L. Use of cross-sectional imaging for tight monitoring of inflammatory bowel diseases. Clin Gastroenterol Hepatol 2020; 18 (06) 1309-1323.e4
  • 78 Allocca M, Fiorino G, Bonovas S. et al. Accuracy of Humanitas Ultrasound Criteria in assessing disease activity and severity in ulcerative colitis: a prospective study. J Crohn's Colitis 2018; 12 (12) 1385-1391
  • 79 Ahmed EA, Abdelatty K, Mahdy RE, Emara DM, Header DA. Computed tomography enterocolongraphy in assessment of degree of ulcerative colitis activity. Int J Clin Pract 2021; 75 (10) e14626
  • 80 Jia Y, Li C, Yang X. et al. CT Enterography score: a potential predictor for severity assessment of active ulcerative colitis. BMC Gastroenterol 2018; 18 (01) 173
  • 81 Ordás I, Rimola J, García-Bosch O. et al. Diagnostic accuracy of magnetic resonance colonography for the evaluation of disease activity and severity in ulcerative colitis: a prospective study. Gut 2013; 62 (11) 1566-1572
  • 82 Herrinton LJ, Liu L, Levin TR, Allison JE, Lewis JD, Velayos F. Incidence and mortality of colorectal adenocarcinoma in persons with inflammatory bowel disease from 1998 to 2010. Gastroenterology 2012; 143 (02) 382-389
  • 83 Jess T, Simonsen J, Jørgensen KT, Pedersen BV, Nielsen NM, Frisch M. Decreasing risk of colorectal cancer in patients with inflammatory bowel disease over 30 years. Gastroenterology 2012; 143 (02) 375-81.e1 , quiz e13–e14
  • 84 Söderlund S, Granath F, Broström O. et al. Inflammatory bowel disease confers a lower risk of colorectal cancer to females than to males. Gastroenterology 2010; 138 (05) 1697-1703
  • 85 Siegel CA, Sands BE. Risk factors for colorectal cancer in Crohn's colitis: a case-control study. Inflamm Bowel Dis 2006; 12 (06) 491-496
  • 86 Beaugerie L, Svrcek M, Seksik P. et al; CESAME Study Group. Risk of colorectal high-grade dysplasia and cancer in a prospective observational cohort of patients with inflammatory bowel disease. Gastroenterology 2013; 145 (01) 166-175.e8
  • 87 Shah SC, Ten Hove JR, Castaneda D. et al. High risk of advanced colorectal neoplasia in patients with primary sclerosing cholangitis associated with inflammatory bowel disease. Clin Gastroenterol Hepatol 2018; 16 (07) 1106-1113.e3
  • 88 Moussata D, Allez M, Cazals-Hatem D. et al; the GETAID. Are random biopsies still useful for the detection of neoplasia in patients with IBD undergoing surveillance colonoscopy with chromoendoscopy?. Gut 2018; 67 (04) 616-624
  • 89 Mahmoud R, Shah SC, Ten Hove JR. et al; Dutch Initiative on Crohn and Colitis. No association between pseudopolyps and colorectal neoplasia in patients with inflammatory bowel diseases. Gastroenterology 2019; 156 (05) 1333-1344.e3
  • 90 Reiser JR, Waye JD, Janowitz HD, Harpaz N. Adenocarcinoma in strictures of ulcerative colitis without antecedent dysplasia by colonoscopy. Am J Gastroenterol 1994; 89 (01) 119-122
  • 91 Askling J, Dickman PW, Karlén P. et al. Family history as a risk factor for colorectal cancer in inflammatory bowel disease. Gastroenterology 2001; 120 (06) 1356-1362
  • 92 Rutter M, Saunders B, Wilkinson K. et al. Severity of inflammation is a risk factor for colorectal neoplasia in ulcerative colitis. Gastroenterology 2004; 126 (02) 451-459
  • 93 Yvellez OV, Rai V, Sossenheimer PH. et al. Cumulative histologic inflammation predicts colorectal neoplasia in ulcerative colitis: a validation study. Inflamm Bowel Dis 2021; 27 (02) 203-206
  • 94 Murthy SK, Feuerstein JD, Nguyen GC, Velayos FS. AGA clinical practice update on endoscopic surveillance and management of colorectal dysplasia in inflammatory bowel diseases: expert review. Gastroenterology 2021; 161 (03) 1043-1051.e4
  • 95 Axelrad JE, Shah SC. Diagnosis and management of inflammatory bowel disease-associated neoplasia: considerations in the modern era. Therap Adv Gastroenterol 2020; 13: 1756284820920779