Plain film diagnosis of fulminating ulcerative colitis.

Abstract

Fulminating ulcerative colitis is a grave form of idiopathic ulcerative colitis, and its management is invariably an extremely difficult problem, demanding skillful application of medical and surgical technics. We have recently examined 26 cases of colitis of this type in which a striking and frequently specific appearance of the colon was observed on plain radiographs of the abdomen. The value of the plain film in this condition, apart from its demonstration of colonic distention, has received virtually no attention in the literature, despite the other gross alterations which may be visible in the gas-filled bowel. Because the severity of the illness and the likelihood of perforation often preclude any more elaborate radiological procedures, it seems pertinent to discuss these radiographic changes and relate them to the clinical and pathological aspects of the disease. Large series at this hospital and elsewhere have shown that about one in twenty cases of ulcerative colitis will be of the fulminating variety, either initially or as an exacerbation of pre-existing chronic colonic disease. In our group of 26 cases, more than one-third appeared with the fulminating episode as the initial manifestation. The term fulminating is used by Bockus (1) to describe those cases of acute ulcerative colitis in which “the onset is relatively abrupt and the severity of the attack may reach its peak in two or three weeks. The attack may continue for weeks or months and terminate fatally, pass into a chronic stage, or into a remission.” The clinical picture is striking, with cardinal symptoms of abdominal pain, bloody diarrhea, vomiting, high fever, and prostration, which may develop within a few weeks or occasionally in a few days. Abdominal distention with localized or diffuse tenderness is present, and peristalsis is diminished. Proctoscopy and sigmoidoscopy almost invariably reveal an active ulcerating disease process. The diagnosis, therefore, is usually established on the basis of clinical findings. However, the presence of abdominal pain and distention usually prompts a plain film study and this affords the radiologist an opportunity to make the definitive diagnosis. In any case, it enables him to give valuable confirmatory information. The plain film may also uncover possible complications and additional disease processes, and occasionally, when diarrhea has not been a feature of the illness, clinically unsuspected colitis may be recognized. Pathology Following total colectomy in cases of fulminating colitis, a striking feature frequently found on examination of surgical specimens is irregular thickening of the bowel wall throughout its entire length, or width, or both. The wall is friable and the thickening is due to inflammatory infiltration, primarily of the mucosa, often also of the muscular layer, and even of the serosa.