bubble_chart Overview

Ulcerative colitis is a chronic inflammation of the colon with unknown causes, primarily affecting the colon's mucosa. It manifests as inflammation or ulcers, often involving the rectum and distal colon, but can extend proximally to involve the entire colon.

bubble_chart Clinical Manifestations

Persistent or recurrent mucoid bloody stools, abdominal pain accompanied by varying degrees of systemic symptoms, but attention should not be neglected for the minority of patients presenting only with constipation or no bloody stools. Past medical history and physical examination should pay attention to extraintestinal manifestations such as joints, eyes, oral cavity, liver, and spleen.

bubble_chart Auxiliary Examination

1. Colonoscopy findings

① Multiple shallow ulcers on the mucosa, accompanied by congestion and edema, with lesions mostly starting from the rectum and showing a diffuse distribution. ② The mucosa appears rough with a fine granular texture, mucosal vessels are blurred, fragile and prone to bleeding, or covered with purulent-bloody secretions. ③ Pseudopolyps may be observed, and haustrations of the colon often become blunt or disappear.

2. Mucosal biopsy

Histological examination reveals inflammatory reactions, along with erosions, ulcers, crypt abscesses, abnormal gland arrangement, decreased goblet cells, and epithelial changes.

3. Barium enema findings

① The mucosa appears disorganized or shows fine granular changes. ② Multiple shallow niches or small filling defects. ③ Shortening of the intestinal tract, disappearance of haustrations, presenting a tubular appearance.

5. Surgical resection or pathological anatomy may reveal macroscopic or histological characteristics of ulcerative colitis.

bubble_chart Diagnosis

On the basis of excluding infectious colitis such as bacillary dysentery, amebic dysentery, chronic schistosomiasis, intestinal tuberculosis, as well as Crohn's disease, ischemic colitis, and radiation colitis, the diagnosis can be made according to the following criteria: ① Based on clinical manifestations, one of the three items (1, 2, or 3) in colonoscopy and/or mucosal biopsy can diagnose the disease. ② Based on clinical manifestations and barium enema showing one of items ①, ②, or ③, the disease can be diagnosed. ③ For cases with inconspicuous clinical manifestations but typical colonoscopy or barium enema findings, the disease can be diagnosed. ④ For cases with typical clinical symptoms or a past history but no typical findings on current colonoscopy or barium enema, they should be classified as "suspected diagnosis" and followed up.

Diagnostic Steps

For patients with chronic mucoid bloody stools suspected of having this disease, the following examinations should be performed: ① Multiple stool cultures for dysentery bacilli, smear tests for amebae, and exclusion of dysentery and schistosomiasis based on regional characteristics. ② Sigmoidoscopy or colonoscopy, along with mucosal biopsy. For fulminant or severe cases, the examination may be temporarily deferred. ③ Barium enema to understand the nature, severity, and extent of the lesions, while excluding other diseases.

A complete diagnosis should include the clinical type, severity, extent of lesions, and disease stage.

1. Types: Chronic relapsing type, chronic continuous type, acute fulminant type, extent of lesions, and disease stage.

(Note: ① Initial onset refers to the first episode without a prior history. Fulminant type presents with severe symptoms accompanied by systemic toxic symptoms, complications such as toxic colonic dilation, intestinal perforation, and sepsis. Except for the fulminant type, all other types can be graded to varying degrees and may transform into one another. ② Grade I patients have diarrhea ≤3 times daily, mild or no hematochezia, no fever, tachycardia, or anemia, and normal ESR. Grade II is intermediate between Grade I and Grade III. Grade III patients have diarrhea ≥6 times daily, obvious mucoid bloody stools, temperature >37.5°C, pulse >90/min, hemoglobin <100g/L, and ESR >30mm/1st hour.)

2. Severity: Grade I, Grade II, Grade III.

3. Extent of lesions: Proctitis, rectosigmoiditis, left-sided colitis, right-sided colitis, regional colitis, pancolitis.

4. Disease stage: Active stage, stage of remission.

bubble_chart Treatment Measures

The treatment of ulcerative colitis should adopt a comprehensive approach, including rest, dietary adjustments with a low-residue diet, avoidance of dairy and allergenic foods, and in severe cases, parenteral nutrition (TPN) should be administered to correct {|###|}electrolyte imbalances, supplement proteins, improve overall condition, address psychological factors, and provide symptomatic treatment.

I. Pharmacological Treatment of Ulcerative Colitis

1. Sulfasalazine (SASP) and Its Derivatives SASP has been used for many years in the treatment of ulcerative colitis. An oral dose of 4–6 g/day achieves good efficacy in 64–77% of patients. After symptom relief, a maintenance dose of 2 g/day for at least one year keeps 89% of patients asymptomatic. Higher doses of SASP improve efficacy but also increase side effects. In the colon, SASP is cleaved by bacterial azoreductase into 5-aminosalicylic acid (5-ASA) and sulfapyridine. The former is the active therapeutic component, while the latter is responsible for side effects. Taking 5-ASA alone is ineffective because it is absorbed in the upper digestive tract, leaving insufficient amounts to reach the colon. In recent years, new oral dosage forms of 5-ASA, such as Pentasa, Asacol, Olsalazine, Poly-5-ASA, and Balsalazide, have been developed. These formulations, lacking sulfapyridine, reduce side effects. Many researchers have noted that topical administration (e.g., SASP or 5-ASA suppositories or enemas) increases local drug concentration and prolongs its duration, enhancing efficacy. Some reports suggest that combining topical and systemic therapy has synergistic effects, allowing for reduced oral SASP doses. The therapeutic mechanism involves inhibiting leukotriene and prostaglandin production, as well as free radical reactions. Side effects include rashes, leukopenia, liver and kidney damage, and pancreatitis, with incidence rates positively correlated with dosage.

2. 4-Aminosalicylic Acid (4-ASA) Also known as PAS, 4-ASA is an anti-{|###|}subcutaneous nodule agent. Administered as a 2 g solution in 100 ml water for daily retention enema, it achieves an 83% efficacy rate after 8 weeks. Ginsberg et al. reported that oral 4-ASA at 4 g/day in divided doses for 12 weeks yielded good results in 55% of patients. The mechanism of 4-ASA in treating ulcerative colitis remains unclear.

3. Adrenocorticosteroids These drugs reduce capillary permeability, stabilize cell and lysosomal membranes, modulate immune function, and decrease macrophage and neutrophil infiltration into inflamed areas. They block the formation of leukotrienes, prostaglandins, and thromboxanes, thereby reducing inflammation and rapidly improving clinical symptoms. For active ulcerative colitis, oral prednisone 40–60 mg/day is typical. In severe cases with poor oral response, intravenous hydrocortisone succinate 200–300 mg/day or rectal drip with hydrocortisone succinate 100 mg in 100 ml liquid may be used, which is more effective than retention enema.

Long-term use of glucocorticoids is prone to side effects, so the dosage should be gradually reduced after symptoms improve and discontinued over 2–3 months. The remission rate for ulcerative colitis is approximately 55.7%–88.2%. Continuous long-term maintenance therapy with glucocorticoids does not prevent relapse. In recent years, some new corticosteroids such as Budesonide and Tixocorto pivalate have been developed, which have no systemic side effects and are more effective than other corticosteroids when used for enema treatment of ulcerative colitis. Some have used Fluticasone Propionate, a fluorinated corticosteroid with low systemic bioavailability after oral administration, which is poorly absorbed and mostly reaches the colon. Administered at 5mg four times daily for 4 weeks, its efficacy is slightly inferior to prednisone due to the lower dosage, but increasing the dosage improves efficacy while rarely causing side effects. There are also glucocorticoid foam preparations (Foam), where small doses administered rectally are equally effective as large doses of hydrocortisone retention enemas, and more convenient than enemas.

4. Immunosuppressants and immunomodulators When glucocorticoid therapy is ineffective or intolerable due to side effects, azathioprine, cyclophosphamide, 6-MP, etc., may be used. In recent years, methotrexate and cyclosporin-A (10mg/kg) have shown good efficacy in some cases, but these drugs also carry certain side effects and should be used with caution. Reports also indicate that penicillamine, levamisole, interferon, and 7S-γ globulin have some therapeutic effects.

5. Fish oil As a leukotriene synthesis inhibitor, oral fish oil can provide clinical improvement as an adjunct therapy for mild to grade II active ulcerative colitis. Some reports suggest that combining glucocorticoids and SASP therapy with oral fish oil (5.4g/day) can enhance efficacy.

6. Metronidazole This drug can inhibit intestinal anaerobic bacteria and alleviate ulcerative colitis symptoms. Additionally, metronidazole affects leukocyte chemotaxis and has certain immunosuppressive effects, contributing to its therapeutic benefits. However, high doses or prolonged use may lead to gastrointestinal reactions.

7. Sodium cromoglicate It stabilizes mast cell membranes, prevents degranulation, and inhibits the release of mediators such as histamine, serotonin, and slow-reacting substances, thereby reducing antigen-antibody reaction-induced intestinal injury. Dosage: 200mg orally three times daily before meals, or 600mg as a retention enema. Some reports suggest its efficacy is comparable to 20mg of prednisone.

8. Anti-infective drugs For patients with concurrent infections, targeted antibiotics should be selected. However, antibiotics should not be used routinely to avoid altering the patient's response to SASP.

9. Other medications ① Clonidine inhibits renin and certain neurotransmitter release. Oral administration of 0.15–0.225mg three times daily has shown efficacy in ulcerative colitis. ② Calcium channel blockers like verapamil and nifedipine have antidiarrheal, analgesic, and antisecretory effects. Cinnarizine (50mg four times daily) also demonstrates good efficacy. ③ H₂ receptor blockers such as cimetidine and ranitidine reduce symptoms like frequent bowel movements by inhibiting histamine release from intestinal mast cells. ④ Chloroquine may slow antigen reactions and normalize intestinal epithelial cell function, alleviating ulcerative colitis symptoms. Additionally, free radical scavengers like superoxide dismutase, 5-lipoxygenase inhibitors (e.g., zileuton/A-64077), and ketotifen can also relieve symptoms.

II. Traditional Chinese Medicine (TCM) Treatment

In TCM, ulcerative colitis falls under the categories of "diarrhea," "intestinal disorders," or "recurrent dysentery." The treatment principle follows the "concept of holism," integrating TCM pattern differentiation with Western medical diagnosis. The approach focuses on eliminating pathogens while supporting healthy qi, emphasizing spleen-stomach strengthening and draining dampness-heat. For clearing heat and reducing inflammation, herbs like Coptis Rhizome, Skullcap Root, Chinese Pulsatilla Root, Purslane Herb, Dandelion, and Patrinia are selected. For reinforcing healthy qi and draining dampness, Tangshen, Astragalus Root, Poria, Chinese Yam, Hyacinth Bean, Coix Seed, and White Atractylodes Rhizome are used. Adjustments are made based on individual symptoms. Reports indicate that modified Ginseng, Poria, and White Atractylodes Powder combined with Coptis Regulating Decoction, Chinese Pulsatilla Root combined with Huo Po Xia Ling Decoction, or Pain and Diarrhea Vital Formula combined with Pulsatilla Decoction have achieved good results in treating ulcerative colitis.

TCM Enema Therapy ① For dampness-heat excess syndrome: Skullcap Root 15g, Coptis Rhizome 10g, Ash Bark 10g, Chinese Pulsatilla Root 30g, Peony Root 15g, Common Bletilla Pseudobulb 15g, Pomegranate Rind 15g. ② For spleen deficiency with dampness: Astragalus Root 30g, Coptis Rhizome 10g, Skullcap Root 10g, Purslane Herb 30g, Common Bletilla Pseudobulb 10g, Atractylodes Rhizome 50g, Chinese Gall 5g. Both formulas are decocted in 50–100ml of water, cooled, and administered as a retention enema nightly before sleep for 15 days as one course. Other enema options include Xilei San, Coptis Rhizome extract, Sophora, and Yunnan Baiyao.

Some also use Chinese patent drugs such as Jiechangning, Bupi Yichang Wan, and Jiechangyan Wan in combination with Western medicine to treat ulcerative colitis, achieving good results.

III. Surgical Treatment

Surgical treatment should be performed in cases of complications such as intestinal perforation, toxic megacolon, abscess and fistula formation, refractory pancolitis, failure of medical treatment, or cancer development.

bubble_chart Cure Criteria

1. Recently cured

Clinical symptoms disappeared, and fiber colonoscopy review showed normal mucosa. Medication was discontinued or only maintenance doses were used, with no recurrence observed for 6 months.

2. Effective

Clinical symptoms basically disappeared, and fiber colonoscopy review showed grade I inflammatory reaction and partial pseudopolyp formation in the mucosa.

3. Ineffective

After treatment, there was no improvement in clinical symptoms, endoscopic findings, or pathological examination.

bubble_chart Prognosis

In China, ulcerative colitis is mostly of the chronic relapsing or chronic persistent type. Patients with mild symptoms or those in the stage of remission have a better prognosis, and those with lesions confined to the rectum also have a favorable prognosis. Individuals over 60 or under 20 years old often experience more severe conditions, and those with complications, hypokalemia, hypoalbuminemia, or extensive lesions have a poor prognosis. Arthritis and ankylosing spondylitis do not affect the prognosis. The prognosis is worse in cases complicated by colonic perforation or massive hemorrhage. Patients with a disease course exceeding 10 years have a higher risk of cancer development.

bubble_chart Prevention

Reduce intake of allergenic foods and gut-damaging medications, minimize mental stress and trauma, avoid infections, and maintain prolonged maintenance therapy to reduce recurrence.

bubble_chart Differentiation

1. Chronic bacterial dysentery

often has a history of acute bacterial dysentery, responds to antibacterial treatment, and fecal culture isolates dysentery bacilli. Colonoscopy with culture of mucopurulent secretions yields a higher positive rate.

2. Chronic amebic dysentery

primarily affects the right colon but can also involve the left colon. The colonic ulcers are deep with sharply defined edges, and the mucosa between ulcers appears normal. Amebic trophozoites or cysts can be found in feces or secretions obtained during colonoscopy. Antiamebic treatment is effective.

3. Schistosomiasis

involves a history of exposure to contaminated water in endemic areas. Fecal examination reveals schistosome eggs, and hatching tests for miracidia are positive. During the acute phase, proctoscopy shows yellowish-brown granules on the rectal mucosa, and biopsy smears or histopathological examination may reveal schistosome eggs. Patients often present with hepatosplenomegaly.

4. Crohn’s disease

Key differentiating features are listed in Table 1.

Table 1: Differentiation between ulcerative colitis and colonic Crohn’s disease

5. Irritable bowel syndrome

Stool contains mucus but no pus or blood, may alternate between constipation and diarrhea, often accompanied by abdominal pain, abdominal distension and fullness, borborygmus, and systemic neurological Functional symptoms. Various examinations show no significant organic lesions, and symptoms are closely related to emotions and mental state.

6. Intestinal cancer

More common in middle-aged and elderly, rectal examination often reveals a mass, fecal occult blood is often positive, X-ray barium enema and fiber colonoscopy have diagnostic value.

It is noteworthy that this disease is easily confused with chronic bacillary dysentery. Both present with chronic pus and blood in stool, and colonoscopy shows chronic inflammation, especially when no specific lesions such as fragile intestinal mucosa prone to bleeding, abnormal gland arrangement, crypt abscesses, or changes in haustra on barium enema are found. Only chronic inflammation or "spiculated or serrated" shadows are seen, leading to misdiagnosis. The author studied 16 cases of chronic pus and blood in stool with colonoscopy reports of "chronic colitis" and barium enema showing "spiculated or serrated" shadows, diagnosed as ulcerative colitis, and found 6 cases were actually chronic bacillary dysentery. All were identified after multiple (3-6 times) prednisone stimulation (oral prednisone 40mg daily for 3 days before stool culture) and stool culture revealed Shigella flexneri, serving as a cautionary example. Other conditions requiring differentiation include intestinal tuberculosis, ischemic colitis, pseudomembranous colitis, radiation colitis, intestinal tumors, and colonic diverticulitis.