45 Years Old Male With Abdominal Pain And Diarrhea For 3 Weeks

A 45 years old male with a past history of inflammatory arthritis presents with abdominal pain and diarrhea. the X- rays that were taken are shown :

Modality X-Ray

Featureless transverse colon and distal descending colon / proximal sigmoid consistent with the lead pipe sign of chronic ulcerative colitis. Additional chronic sacroillitis with ankylosis on the left and partial ankylosis on the right. Asymmetric left hip joint arthropathy.   

X- Ray Modality : Annotated Image

Lead pipe appearance of the colon (red arrows). Ankylosis of the left sacroiliac joint and partial ankylosis on the right (yellow arrow). 

Case Discussion:

A nice example of the lead pipe sign of chronic ulcerative colitis and of enteropathy associated arthritis with chronic bilateral sacroillitis and left hip joint arthropathy.

Ulcerative colitis

Ulcerative colitis (UC) is an inflammatory bowel disease which predominantly affects the colon, but also has extraintestinal manifestations.

Epidemiology

Typically ulcerative colitis manifests in young adults (15-40 years of age) and is more prevalent in males but onset of disease after age 50 is also common. A combination of environmental and genetic factors are thought to play a role in the pathogenesis, although the condition remains idiopathic.

Nonsmoking is associated with UC; ex-smokers are at higher risk for developing UC than non- smokers

Clinical presentation

Clinically patients have chronic diarrhoea (sometimes bloody) associated with tenesmus, pain and fever.

Pathology

Unlike Crohn's disease which is characteristically a transmural disease, ulcerative colitis is usually limited to the mucosa and submucosa. Chronic disease is associated with a significantly elevated malignancy risk, of up to 0.5-1.0% per year after 10 years of disease.

The diagnosis is often made with endoscopy, which also allows biopsy of any suspicious areas.

Extra-intestinal manifestations

• throcis manifestations of ulcerative colitis.
• uveitis and iritis 
• erythema nodosum and pyoderma gangrenosum 
• thrombotic complications 
• fatty liver 
• seronegative spondyloarthropathy.

Complications

Approximately 10-15% of cases initially presenting as ulcerative colitis can later progress to Crohn's disease

Treatment and prognosis

Total colectomy is curative of both the intestinal symptoms and of the potential risk of colorectal carcinoma. Medical therapy is able in some cases to control colonic disease but does not remove the need to carefully and regularly screen for malignancy.

Due to close surveillance patients with ulcerative colitis have a normal or even slightly improved survival compared to normal population . This is clearly not the case if the disease is not diagnosed or treatment not available.