Endoscopic involvement in ulcerative colitis is characterized by initial manifestation in the rectum, with continuous spread and a clear delimitation from the healthy area.
Mild flare-ups are characterized by erythema and edema of the mucosa, with disappearance of the vascular pattern, a fine diffuse point erosion pattern and friability.
Figure 1: Mild ulcerative colitis. Continuous involvement of the mucosa up to the transverse colon. Edematous mucosa with a fine diffuse point erosion pattern and scarce mucopurulent exudate.
Figure 3: Ulcerative colitis showing moderate flare-up; confluent superficial ulcers are observed with areas of spontaneous bleeding and denudation of the mucosa, as well as abundant mucopurulent exudate.
In patients with severe endoscopic involvement deep ulcers are seen that may even affect the full thickness of the wall, with irregular or geographic margins. Highly evolved cases may exhibit endoscopic features similar to the ulcers found in Crohn’s disease.
Figure 4. Left ulcerative colitis: moderate-severe endoscopic involvement; extensive longitudinal ulcers of some depth, extending over a mucosa with continuous disease involvement. (Clinical case 6).
Figure 5. Ulcerative pancolitis; severe endoscopic involvement; continuous involvement with extensive and confluent longitudinal ulcers that exhibit some depth upon progressing proximally. Important edema and mucosal friability. (Clinical case 7)
Figure 6. Patient with ulcerative colitis showing severe endoscopic involvement. Deep, evolved punch-out ulcerations. The endoscopic view may be confused with Crohn’s disease.
Severe endoscopic lesions, with ulcers of large size and depth, and showing serpiginous or geographic margins, are found in the context of severe clinical flare-ups with a high incidence of resistance to corticosteroid therapy. In the same way as in Crohn’s disease, increased severity of the endoscopic lesions is correlated to a poorer clinical course and a high incidence of colectomies. In fact, in the context of severe ulcerative colitis, the endoscopic appearance of the lesions may influence the medical-surgical treatment options.
Figure 7. Ulcerative colitis. Severe flare-up. Refractory to corticosteroids. Endoscopy showed very notorious ulcers of large size and depth, in the context of a serious clinical picture that caused us to decide surgical treatment. In these situations, joint evaluation of the clinical, laboratory test and imaging data will allow us to choose the best treatment option on an individualized or case-by-case basis. (Clinical case 8)
Sustained inflammation of the colonic mucosa may lead to shortening and rectification of the colon and to the appearance of lesions such as pseudopolyps or strictures.
Figure 8. Long-evolving ulcerative colitis. Diffuse pseudo-polyposis in relation to sustained inflammatory episodes.
These lesions are considered to imply an increased risk of developing colorectal cancer in the context of long-standing colitis – a fact that should be taken into account when establishing endoscopic follow-up protocols. (Clinical case 7)