Ulcerative colitis

Case contributed by Dr Bruno Di Muzio

Presentation

Abdominal pain and diarrhoea.

Patient Data

Age: 45 years
Gender: Male
X-ray

Abdominal radiographs

Thumbprint sign along the transverse colon suggestive of colitis. 

The patient had colonoscopy and treatment has been initiated with improvement on the following days.  

CT

CT Abdomen and pelvis (1 month later)

The imaging features are those of diffuse colitis with no evidence of penetrating disease or strictures. No bowel dilation to suggest toxic megacolon. The left colon has loss of normal haustral markings. No signs of malignancy. 

Macroscopy:  Labelled "Colon". Total colectomy including terminal ileum 20 x 25 mm, caecum/large bowel 580 x 70 mm and appendix 110 x 7 mm. Fat attached the length of the bowel. On opening within the caecum (26 mm from the proximal margin) extending to 20 mm from the distal resection, margin mucosa appears tan/brown and demonstrates a pseudopolypoid appearance with areas of ulceration and haemorrhage (without any skip lesions). In addition, 200 mm from the proximal resection margin there is a full-thickness defect measuring 40 x 25 mm, which may represent tear at the time of surgery. No lesions are identified. Appendix appears pale tan. Proximal margin inked black, distal green, yellow surrounding site of the defect.

Microscopy:  Multiple sections taken from proximal to distal, show similar changes with extensive areas of ulceration that extend into the deep aspect of submucosa associated with overlying fibrin and acute and chronic inflammation with intervening areas of pseudopolyps within which the surface mucosa shows crypts with regenerative atypia branching and an increase in chronic inflammation in the lamina propria with some foci of acute active colitis. The changes become worse as the biopsies taken towards the distal aspect. Muscularis propria shows a light chronic inflammatory cell infiltrate, and the serosa is not involved. There is no evidence of any granulomata. The proximal small bowel wall is unremarkable. The caecal proximal aspect shows early branching and regenerative atypia. There is no evidence of any dysplasia and no malignancy. 

Conclusion:  Colon–features in keeping with active ulcerative colitis. No evidence of dysplasia or malignancy.

Case Discussion

Imaging features are those of colitis. The diagnosis of ulcerative colitis was made at endoscopy biopsies.

Given the increased risk of malignancy and clinical setting, total colectomy was discussed with the patient and further performed. The histopathology confirmed features of UC. 

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Case information

rID: 60589
Published: 31st May 2018
Last edited: 31st May 2018
Inclusion in quiz mode: Included

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