1. INTRODUCTION
   1. > 15 - 30 yo
   2. Absence of rectal involment: 5% in adults
   3. Absence of rectal involment: Up 1/3 in children
   4. Up to 46% of patients with proctitis and 70% with left-sided colitis may develop extensive colitis on follow-up
   5. Potential precipitants: Recent smoking cessation, NSAID use and enteric infections
2. DIAGNOSIS, ASSESSMENT, AND PROGNOSIS OF ULCERATIVE COLITIS
   1. Symptoms: Bloody diarrhea, mucous, urgency, tenesmus, and abdominal cramping
   2. Extraintestinal manifestations: joint, skin, ocular, oral manifestations, and hepatobiliary involvement
   3. Infectious etiologies should be excluded
      1. Clostridium infection
         1. Newly diagnosed or relapsing IBD ranges from 5% to 47%.
      2. Other:
         1. Escherichia coli (E. coli O157:H7), Salmonella, Shigella, Yersinia, and Campylobacter and parasitic infections such as amebiasis
   4. Colonoscopy
      1. Endoscopic features
         1. Loss of vascular markings, granularity and friability of the mucosa, erosions, and, in the setting of severe inflammation, deep ulcerations and spontaneous bleeding
      2. Biopsies of affected and unaffected areas should be obtained
         1. Histologic extension may be seen even in endoscopically normal-appearing colon
   5. Routine upper endoscopic evaluation is not required
      1. Gastritis and erosions may be seen in up to one-third of patients with UC
   6. Scores
      1. Proposed American College of Gastroenterology Ulcerative Colitis Activity Index
      2. Mayo endoscopic subscore and the Ulcerative Colitis Endoscopic Index of Severity
   7. Extent and severity
      1. Extension
         1. Proctitis, Left-side colitis, Extensive colitis (beyond the splenic flexure)
      2. Severity
         1. Mildly, moderately, and severely active
         2. Truelove and Witts
            1. Mild
            2. <4 bowel movements daily, normal temperature, heart rate, hemoglobin (>11 g/dL), and ESR (<20 mm/hr)
            3. Severe
            4. Bowel frequency greater than 6 times a day in conjunction with fever, tachycardia, anemia, or an elevation in ESR
         3. Mayo endoscopic score
            1. 0: Normal
            2. 1: Erythema, decreased vascular pattern, mild friability
            3. 2: Marked erythema, absent vascular pattern, friability, erosions
            4. 3: Spontaneous bleeding, ulceration
   8. Fecal calprotectin
      1. Nonspecific neutrophilic marker of inflammation. Elevated in infectious and inflammatory colitis but not in noninflammatory causes of diarrhea such as irritable bowel syndrome
   9. Poor pronostic factors
      1. Age <40 yr at diagnosis
      2. Extensive colitis
      3. Severe endoscopic disease (Mayo endoscopic subscore 3, UCEIS >= 7)
      4. Hospitalization for colitis
      5. Elevated CRP
      6. Low serum albumin
3. GOALS FOR MANAGING PATIENTS WITH ULCERATIVE COLITIS
   1. Symptomatic remission
      1. Improvement of patient-reported outcomes
   2. Endoscopic healing
      1. Restoration of intact mucosa without friability
         1. Mayo endoscopic subscore 0 or 1
   3. Deep remission
      1. Combination of symptomatic remission and endoscopic healing
         1. Preferred goal of management
   4. Histologic remission
      1. Associated with some improved clinical outcomes but has not yet been validated prospectively as an end point of treatment
         1. Active microscopic inflammation (defined by the presence of mucosal neutrophils) is predictive of clinical relapse, hospitalization, and steroid use
   5. Fecal calprotectin
      1. When endoscopy is not feasible or available to assess for mucosal healing
         1. The best sensitivity of 90% (87.9–92.9) was achieved at a cutoff level of 50 mg/g and the best specificity of 78.2% (75.7–80.6) was achieved for cutoff levels greater than 100 mg/g
4. COLORECTAL CANCER PREVENTION IN ULCERATIVE COLITIS
   1. Screening
      1. UC of extent greater than the rectum
         1. Should start 8 years after diagnosis
            1. 1- to 3-year intervals based on the combined risk factors for CRC
      2. UC and primary sclerosing cholangitis
         1. Screening colonoscopy at the time of diagnosis of UC and surveillance annually thereafte
            1. The inflammatory activity in UC is less severe, and patients may have had disease longer than was previously known
      3. Most neoplasia
         1. When dysplasia in UC is not resectable or is multifocal
            1. Should be referred for proctocolectomy
   2. Risk factors
      1. Longer duration of disease
      2. Increased inflammatory activity
      3. Younger age of diagnosis
      4. Greater extent of colonic inflammation
      5. Coexisting PSC
      6. Family history of a first-degree relative with CRC
   3. Dysplasia
      1. Classical description
         1. Flat, spreading lesions rather than sessile or pedunculated polyps
      2. When is confirmed
         1. Associated with a high rate of synchronous or metachronous cancer
            1. If these can be completely resected
            2. Patients can be followed with ongoing surveillance rather than surgery
            3. Biopsies of the flat mucosa surrounding the area should be obtained to confirm that no residual neoplasia is left in situ
      3. The rates of CRC is decreasing because
         1. Better control of inflammation
         2. Access to surgery for medically resistant disease (removing at-risk patients from these cohorts earlier)
      4. Nontargeted (“random”) biopsies
         1. Not recommended because most neoplasia was visible in the majority of patients
      5. “DALM” (dysplasia-associated lesion or mass) should no longer be used to describe neoplasia
   4. Confirmed CRC
      1. 2- or 3-stage creation of continent reservoir IPAA