History

Fact Explanation
Bleeding per rectum Patients present with bleeding per rectum with frequent stools and mucus discharge with stools. Proctitis causes rectal bleeding and mucus discharge, sometimes accompanied by tenesmus. Some patients pass frequent, small-volume fluid stools, while others are constipated and pass pellet-like stools. Proctosigmoiditis causes bloody diarrhoea with mucus. Extensive colitis causes bloody diarrhoea with passage of mucus. Patients with mild attacks have rectal bleeding or diarrhoea with four or fewer motions per day, in the absence of systemic signs of disease. Patients with moderate attacks get more than four motions per day but no systemic signs of illness. Patients with severe attacks get more than four motions a day together with one or more signs of systemic illness: fever over 37.5°C, tachycardia more than 90 per min, hypoalbuminaemia less than 30 g/l, weight loss more than 3 kg.[1], [2],[3],[6]
Abdominal pain Associated with rectal discharge. This is mostly seen in elderly patients and in severe extensive colitis. [1], [2],[3], [6]
Fever Constitutional symptoms as fever, anorexia, malaise and weight loss occur in severe proctosigmoiditis and extensive colitis. [1], [2],[3], [6]
More likely among 20 to 40 year olds It is uncommon before the age of 10 years, and most patients are between the ages of 20 and 40 years at the time of diagnosis. [6]
Past episodes In most of patients this disease is chronic and characterised by relapses and remissions. [1],[2] [3],[6]
Extra-intestinal manifestations: Skin and mucocutaneous complications Erythema nodosum presents as painful, raised subcutaneous lesions located on extensor surfaces of the extremities. Pyoderma gangrenosum is a necrotic ulcer with expanding borders of erythema. At time of onset it is a noninfectious pustule and eventually expands outwards to develop painful ulcers. Usually occurs on the legs, but can appear anywhere on the skin. Aphthous ulcers are small, round, painful, and heal within 2 weeks without scarring, while major recurrent ulcers are larger, can last for 6 weeks, and frequently cause scarring. [1], [2],[3], [4],[5], [6]
Extra-intestinal manifestations: Musculoskeletal complications Patient may complain about joint pain/ swelling or muscle pain due to arthritis, myopathies and metabolic bone disorders. Patients get lower back pain and relieve of symptoms with exercising due to the associated Ankylosing Spondylitis. [1], [2],[3], [4],[5], [6]
Extra-intestinal manifestations: Eye involvement In episcleritis the inflammation is usually segmental and bilateral in distribution and associated with eye discomfort, irritation, redness, and tearing. there is usually no visual impairment or purulent discharge. Patients with uveitis have photophobia, blurred vision, pain, and conjunctival injection. In scleritis patients get deep eye pain with radiation to eyebrows, cheeks and temples, eye redness, tearing, photophobia and blurred vision. Severe cases can ultimately lead to blindness. Optic neuritis causes rapid and progressive reduction in vision. Untreated optic neuritis can lead to permanent loss of vision.
References
  1. HARDY TL, BULMER E. ULCERATIVE COLITIS: A SURVEY OF NINETY-FIVE CASES Br Med J [online] 1933 Nov 4, 2(3800):812-815 [viewed 22 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2369581
  2. SONNENBERG A. Disability from inflammatory bowel disease among employees in West Germany. Gut [online] 1989 Mar, 30(3):367-370 [viewed 22 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1378460
  3. EADEN J A. The risk of colorectal cancer in ulcerative colitis: a meta-analysis. [online] 2001 April, 48(4):526-535 [viewed 22 July 2014] Available from: doi:10.1136/gut.48.4.526
  4. LOHMULLER JL, PEMBERTON JH, DOZOIS RR, ILSTRUP D, VAN HEERDEN J. Pouchitis and extraintestinal manifestations of inflammatory bowel disease after ileal pouch-anal anastomosis. Ann Surg [online] 1990 May, 211(5):622-629 [viewed 22 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1358238
  5. JIANG, X. L., CUI H. F. (2002). An analysis of 10218 ulcerative colitis cases in China. World Journal of gastroenterology, 8(1), 158-161. [viewed 22 July 2014] Available from: http://www.wjgnet.com/1007-9327/8/158.pdf?q=huaren
  6. PARRAY FQ, WANI ML, MALIK AA, WANI SN, BIJLI AH, IRSHAD I, NAYEEM-UL-HASSAN. Ulcerative Colitis: A Challenge to Surgeons Int J Prev Med [online] 2012 Nov, 3(11):749-763 [viewed 22 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3506086

Examination

Fact Explanation
Apparently normal during physical examination In mild disease there are no positive physical examination signs. [1],[2]
Tachycardia Patients with severely active disease will have signs of toxicity with fever and tachycardia.[1],[2]
Abdominal examination During active periods, the abdomen, especially in proximity to the colon, is tender to palpation. Acute attacks or fulminating forms of the disease can present much like an acute surgical abdomen, with accompanying fever and decreased bowel sounds. In patients with toxic megacolon, abdominal distention may be identified.[1],[2]
clubbing Prevalence of finger clubbing is significantly higher in patients with Crohn's disease than in those with ulcerative colitis. Disease activity and fibrosis are important stimuli in an afferent pathway of a finger-clubbing reflex commonly mediated by the vagus nerve, though other autonomic pathways may also play a part.[1],[3]
Aphthous oral ulcers About 4.3% of ulcerative colitis(UC) patients experience recurrent aphthous stomatitis and symptom onset often parallels UC disease activity. Minor aphthous ulcers are small, round, painful, and heal within 2 weeks without scarring, while major recurrent ulcers are larger, can last for 6 weeks, and frequently scar.[1],[2],[4],[5]
Erythema nodosum Affects about 3% of patients with UC. Lesions affect females with UC more frequently than men and this rarely precedes the initial diagnosis of UC. Typical lesions present as painful, raised subcutaneous lesions located on extensor surfaces of the extremities. However, UC patients almost always have lesions on the anterior surface of the legs. The skin nodules are non ulcerating and resemble a bruise on the skin.lesions mirror UC disease activity and worsen with colonic flares. The average lag time between initial UC diagnosis and appearance of erythema nodosum is 5 years [1],[2],[4],[5]
Red eye Episcleritis, uveitis and conjunctivitis are the most frequent eye manifestations. Females are affected more frequently than males and eye manifestations were found to be well correlated with UC flares. Episcleritis; the inflammation is usually segmental and bilateral in distribution and associated with eye discomfort, irritation, redness, and tearing. However, there is usually no visual impairment or purulent discharge. Uveitis; symptoms of uveitis include photophobia, blurred vision, pain, and conjunctival injection. Anterior uveitis or iritis is distinguished from other causes of red eye by slit lamp examination and leukocytes seen in the anterior chamber is diagnostic of anterior uveitis. Posterior uveitis can be diagnosed by one of two ways: either by direct visualization of the active chorioretinal inflammation and/or by detecting leukocytes in the vitreous humor by slit lamp or indirect ophthalmoscope. [1],[2],[4],[5]
joint examination Musculoskeletal complications are quite common and affect approximately 25% of all patients. Even though axial arthritis including ankylosing spondylitis can occur the risk of developing peripheral arthritis is higher in UC patients and increases with colonic involvement. Swollen, reddish, tender joints with limited range of movements can be seen in examination.[1],[2],[4],[5]
References
  1. PARRAY FQ, WANI ML, MALIK AA, WANI SN, BIJLI AH, IRSHAD I, NAYEEM-UL-HASSAN. Ulcerative Colitis: A Challenge to Surgeons Int J Prev Med [online] 2012 Nov, 3(11):749-763 [viewed 22 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3506086
  2. WALJEE AK, JOYCE JC, WREN PA, KHAN T, HIGGINS PD. Patient reported symptoms during an ulcerative colitis flare: A Qualitative Focus Group Study Eur J Gastroenterol Hepatol [online] 2009 May, 21(5):558-564 [viewed 22 July 2014] Available from: doi:10.1097/MEG.0b013e328326cacb
  3. KITIS G, THOMPSON H, ALLAN RN. Finger clubbing in inflammatory bowel disease: its prevalence and pathogenesis. Br Med J [online] 1979 Oct 6, 2(6194):825-828 [viewed 22 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1596648
  4. BAUMGART DC. The Diagnosis and Treatment of Crohn's Disease and Ulcerative Colitis Dtsch Arztebl Int [online] 2009 Feb, 106(8):123-133 [viewed 22 July 2014] Available from: doi:10.3238/arztebl.2009.0123
  5. EDWARDS F. C., TRUELOVE S. C.. The course and prognosis of ulcerative colitis: Part I Short-term prognosis. Gut [online] 1963 December, 4(4):299-308 [viewed 22 July 2014] Available from: doi:10.1136/gut.4.4.299

Differential Diagnoses

Fact Explanation
Crohn's disease (CD) Ulcerative colitis and Crohn's disease are chronic inflammatory bowel diseases which pursue a protracted relapsing and remitting course, usually extending over years. The diseases have many similarities and it is sometimes impossible to differentiate between them. A crucial distinction is that ulcerative colitis only involves the colon, while Crohn's disease can involve any part of the gastrointestinal tract from mouth to anus.In CD pain is commonly experienced in the lower right abdomen, whereas in UC pain is common in the lower left part of the abdomen. In CD Colon wall appearance may be thickened and may have a rocky appearance whereas in UC Colon wall is thinner and shows continuous inflammation. In CD ulcers occur along the digestive tract are deep and may extend into all layers of the bowel wall whereas in UC mucus lining of large intestine may have ulcers, but they do not extend beyond the inner lining. In CD bleeding from the rectum during bowel movements is not common whereas in UC bleeding from the rectum during bowel movements is common. [1]
Infective enterocolitis Distinguishing the first attack of acute colitis from infection is difficult. In general, diarrhoea lasting longer than 10 days in is unlikely to be the result of infection especially in Western countries. A history of foreign travel, unhygienic food consumption, antibiotic exposure (pseudomembranous colitis) or homosexual contact suggests infection. Stool microscopy, culture and examination for Clostridium difficile toxin or for ova and cysts, sigmoidoscopy and rectal biopsy, blood cultures and serological tests for infection are useful. [2]
Colonic carcinoma Those patients also present with bleeding per rectum. Endoscopic investigations are important to exclude carcinoma.[3]
Ischemic colitis As these patients also have inflamed colon they also can present as UC. . None of the symptoms and signs is specific. Most patients present with a sudden onset of crampy abdominal pain, diarrhea and an urge to defecate. The pain is mild, located over the affected bowel, usually to the left side of the lower abdomen and hypogastrium, followed by mild rectal bleeding within 24 h. The blood may be bright red or maroon, frequently mixed with the stools. Rectal bleeding is usually minimal. [4]
Diverticulitis These patients may present with abdominal pain, change in bowel habit, mostly diagnosed by CT evaluation. [5]
References
  1. FERGUSON A. Ulcerative colitis and Crohn's disease. BMJ [online] 1994 Aug 6, 309(6951):355-356 [viewed 22 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2541214
  2. NEAL K. R, HEBDEN J., SPILLER R.. Prevalence of gastrointestinal symptoms six months after bacterial gastroenteritis and risk factors for development of the irritable bowel syndrome: postal survey of patients. BMJ [online] 1997 March, 314(7083):779-779 [viewed 22 July 2014] Available from: doi:10.1136/bmj.314.7083.779
  3. LI FY, LAI MD. Colorectal cancer, one entity or three J Zhejiang Univ Sci B [online] 2009 Mar, 10(3):219-229 [viewed 22 July 2014] Available from: doi:10.1631/jzus.B0820273
  4. THEODOROPOULOU Α, ΚOUTROUBAKIS IE. Ischemic colitis: Clinical practice in diagnosis and treatment World J Gastroenterol [online] 2008 Dec 28, 14(48):7302-7308 [viewed 22 July 2014] Available from: doi:10.3748/wjg.14.7302
  5. BEN YAACOUB I, BOULAY-COLETTA I, JULLèS MC, ZINS M. CT findings of misleading features of colonic diverticulitis Insights Imaging [online] , 2(1):69-84 [viewed 22 July 2014] Available from: doi:10.1007/s13244-010-0051-6

Investigations - for Diagnosis

Fact Explanation
Endoscopy with biopsy Endoscopy can be very valuable in establishing the final diagnosis, excluding other potential etiologies in patients presenting with bloody diarrhea, delineating the extent and activity of mucosal inflammation, and obtaining mucosal biopsies for histologic evaluation. Endoscopy can be particularly useful in differentiating ulcerative colitis from Crohn's colitis. Since ulcerative colitis involves the rectum in 90–95% of cases, flexible sigmoidoscopy is the first step in diagnosis. Mild cases may only show a loss of normal vascular pattern, a granular texture, and micro hemorrhages when the friable mucosa is touched or wiped. When the disease is moderately active, the mucosa becomes more grossly pitted, and spontaneous bleeding is often present. In severe cases, there is macroulceration and profuse bleeding, usually accompanied by a purulent exudate.[1]
Barium studies A lower Gastrointestinal series or barium enema examination of the colon is useful in most patients, although potentially dangerous in those with toxic megacolon. More mild cases of acute ulcerative colitis may be manifested by a diffusely granular appearance, which can also be seen in more detail on air-contrast barium enema. In more advanced cases, the colon develops irregular margins with spiculated and undermining collar-button ulcers that can be observed on full-column barium enema. End-stage or “burned-out” ulcerative colitis is characterized by shortening of the colon, loss of normal redundancy in the sigmoid region and at the splenic and hepatic flexures, disappearance of the haustral pattern, a featureless mucosa, absence of discrete ulceration, and narrowed caliber of the bowel. [1]
Abdominal ultrasound May identify thickened small bowel loops but it cannot be used to distinguish between ulcerative colitis and Crohn disease.[2]
Stool culture Stool cultures are performed to exclude enteric infection [2]
References
  1. PARRAY FQ, WANI ML, MALIK AA, WANI SN, BIJLI AH, IRSHAD I, NAYEEM-UL-HASSAN. Ulcerative Colitis: A Challenge to Surgeons Int J Prev Med [online] 2012 Nov, 3(11):749-763 [viewed 22 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3506086
  2. WALJEE AK, JOYCE JC, WREN PA, KHAN T, HIGGINS PD. Patient reported symptoms during an ulcerative colitis flare: A Qualitative Focus Group Study Eur J Gastroenterol Hepatol [online] 2009 May, 21(5):558-564 [viewed 22 July 2014] Available from: doi:10.1097/MEG.0b013e328326cacb

Investigations - Fitness for Management

Fact Explanation
Abdominal X ray plain abdominal radiograph may be useful initially, especially since more invasive imaging techniques can have serious risks. An abdominal film may demonstrate colonic dilation or toxic megacolon in 3-5% of patients. Although this dilation is most frequently observed in the transverse colon, it can occur anywhere in the colon. A plain radiograph is also useful for detecting free air within the peritoneal cavity, indicating a potential perforation of the diseased colon.[1]
Stool culture Stool cultures are performed to exclude superimposed enteric infection [2]
References
  1. PARRAY FQ, WANI ML, MALIK AA, WANI SN, BIJLI AH, IRSHAD I, NAYEEM-UL-HASSAN. Ulcerative Colitis: A Challenge to Surgeons Int J Prev Med [online] 2012 Nov, 3(11):749-763 [viewed 22 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3506086
  2. WALJEE AK, JOYCE JC, WREN PA, KHAN T, HIGGINS PD. Patient reported symptoms during an ulcerative colitis flare: A Qualitative Focus Group Study Eur J Gastroenterol Hepatol [online] 2009 May, 21(5):558-564 [viewed 22 July 2014] Available from: doi:10.1097/MEG.0b013e328326cacb

Investigations - Followup

Fact Explanation
Endoscopy with biopsy Useful in assessing management plan. Endoscopic assessment of disease activity is important in guiding decisions regarding management and in the determination of prognosis. Patients with long-standing ulcerative colitis (> 8 years' duration) are at increased risk of developing colorectal cancer, so they have to be screened [1]
Full blood count Done to identify anaemia or thrombocytosis [2]
References
  1. PARRAY FQ, WANI ML, MALIK AA, WANI SN, BIJLI AH, IRSHAD I, NAYEEM-UL-HASSAN. Ulcerative Colitis: A Challenge to Surgeons Int J Prev Med [online] 2012 Nov, 3(11):749-763 [viewed 22 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3506086
  2. WALJEE AK, JOYCE JC, WREN PA, KHAN T, HIGGINS PD. Patient reported symptoms during an ulcerative colitis flare: A Qualitative Focus Group Study Eur J Gastroenterol Hepatol [online] 2009 May, 21(5):558-564 [viewed 22 July 2014] Available from: doi:10.1097/MEG.0b013e328326cacb

Investigations - Screening/Staging

Fact Explanation
Endoscopy with biopsy Extent of the disease is defined by the endoscopy with biopsy Extensive disease has evidence proximal to the splenic flexure Left-sided disease in presents in the descending colon up to, the splenic flexure but not proximal to it. Proctosigmoiditis, the disease is limited to the rectum with or without sigmoid colonic involvement.
References
  1. LEIGHTON J. A., SHEN B., BARON T. H., ADLER D. G., DAVILA R., EGAN J. V., FANELLI R. D. ASGE guideline: endoscopy in the diagnosis and treatment of inflammatory bowel disease. Gastrointestinal endoscopy, 63(4), 558-565. [viewed 22 July 2014] Available from: http://www.asge.org/assets/0/71542/71544/c651d0924af94f10b61f875c5ac5f2b0.pdf

Management - General Measures

Fact Explanation
Management of severe attack These patients must be regarded as medical emergencies and require immediate admission to hospital. They must be examined at least twice a day. It is important to monitor vital signs (pulse, temperature and blood pressure). Weight needs to be recorded at admission and twice a week while in hospital. A stool chart should be kept. Increasing abdominal girth is a potential sign of megacolon devel.[1],[2],[3]
Maintenance therapy Life-long maintenance therapy is recommended for all patients with extensive disease and patients with distal disease who relapse more than once a year. Patients have to adhere to the drug treatment plan. No specific diet restrictions are required. [1][2][3]
References
  1. PARRAY FQ, WANI ML, MALIK AA, WANI SN, BIJLI AH, IRSHAD I, NAYEEM-UL-HASSAN. Ulcerative Colitis: A Challenge to Surgeons Int J Prev Med [online] 2012 Nov, 3(11):749-763 [viewed 23 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3506086
  2. NANDA K, MOSS AC. Update on the management of ulcerative colitis: treatment and maintenance approaches focused on MMX® mesalamine Clin Pharmacol [online] :41-50 [viewed 24 July 2014] Available from: doi:10.2147/CPAA.S26556
  3. NAVANEETHAN U, SHEN B. Pros and Cons of Medical Management of Ulcerative Colitis Clin Colon Rectal Surg [online] 2010 Dec, 23(4):227-238 [viewed 23 July 2014] Available from: doi:10.1055/s-0030-1268249

Management - Specific Treatments

Fact Explanation
Mild attacks (rectal bleeding or diarrhoea with four or fewer motions per day and the absence of systemic signs of disease) Usually responds to rectally administered steroids. In those with more extensive disease, oral prednisolone 20–40 mg day is given over a 3- to 4-week period.One of the 5-ASA compounds should be given concurrently. [1], [2],[3]
Moderate attacks( more than four motions per day but no systemic signs of illness) Oral prednisolone 40 mg day, twice-daily steroid enemas and 5-ASA. Failure to achieve remission as an out-patient is an indication for admission. [1], [2],[3]
Severe attacks (more than four motions a day together with one or more signs of systemic illness: fever over 37.5°C, tachycardia more than 90 per min, hypoalbuminaemia less than 30 g l, weight loss more than 3 kg.) Regarded as medical emergencies. Intravenous fluids are given. Blood transfusion is done if Hb < 100 g/l. IV methylprednisolone (60 mg daily) or hydrocortisone is given. Antibiotics given for proven infection. Nutritional support given as necessary. Subcutaneous heparin given for prophylaxis of venous thromboembolism. Opiates and antidiarrhoeal agents have to be avoided. IV cyclosporine (2 mg/kg) or infliximab (5 mg/kg) given to stable patients who are not responding to 3-5 days of corticosteroids. [1], [2],[3]
Medical management - Aminosalicylates (mesalazine , olsalazine, sulfasalazine, balsalazide) It acts by modulating cytokine release from mucosa. They delivered to colon by one of three mechanisms:pH-dependent,time-dependent, or bacterial breakdown by colonic bacteria from a carrier molecule. Available as oral or topical (enema/suppository) preparations. Sulfasalazine causes side-effects in 10-45%: headache, nausea, diarrhoea, blood dyscrasias Other aminosalicylates much better tolerated; diarrhoea, headache in 2-5% Rarely, renal impairment All safe during pregnancy [1],[2],[3]
Medical management - Corticosteroids (prednisolone, hydrocortisone, budesonide) It is an anti-inflammatory drug. Budesonide is a potent corticosteroid efficiently cleared from circulation by liver, thereby minimizing adrenocortical suppression and steroid side-effects. Topical, oral or i.v. preparations are used according to disease severity. Bisphosphonates are co-prescribed to prevent osteopenia.Budesonide considered for active ileitis and ileocolitis. [1],[2],[3]
Medical management - Thiopurines (azathioprine, 6-mercaptopurine) They cause immunomodulation by inducing T-cell apoptosis. Effective 6-18 weeks after starting therapy. Complications in 20%. Flu-like syndrome with myalgia. Leucopenia in 3%. No increased risk of cancer but probable increase in lymphoma. Safe during pregnancy. [1],[2],[3]
Medical management - Methotrexate It is an anti-inflammatory drug. Intolerance occur in 10-18%. Nausea, stomatitis, diarrhoea, hepatotoxicity and pneumonitis can occur as side effects. [1],[2],[3]
Medical management - Ciclosporin They cause suppression of T-cell expansion. Used as 'Rescue' therapy to prevent surgery in ulcerative colitis responding poorly to corticosteroids. Major side-effects in 0-17%: nephrotoxicity, infections, neurotoxicity (including fits) Minor complications in up to 50%: tremor, paraesthesiae, abnormal LFTs, hirsutism [1],[2],[3]
Medical management - Infliximab Given as i.v. infusion 4-8-weekly. They induces apoptosis of inflammatory cells. Used in severe active ulcerative colitis. Anaphylactic reactions can occur after multiple infusions. Contraindicated in the presence of infections; can cause reactivation of tuberculosis. [1],[2],[3]
Medical management - Antibiotics Usually administered on empirical basis in patients with severe colitis where they may help with averting an infection which is life-threatening. [1],[2],[3]
Medical management - Antidiarrhoeal agents (codeine phosphate, loperamide, lomotil) They reduce gut motility and small bowel secretion. Avoided in moderately or severely active disease. May precipitate colonic dilatation. [1],[2],[3]
Surgical management Surgery is indicated in severe or fulminating disease failing to respond to medical therapy,chronic disease with anaemia, frequent stools, urgency and tenesmus, steroid-dependent disease, disease with the risk of neoplastic change, with extraintestinal manifestations and rarely, in severe haemorrhage or stenosis causing obstruction. [1]
Management of acute episode Corticosteroids are the most useful drugs and can be given either locally for inflammation of the rectum or systemically when the disease is more extensive. Indications for urgent surgery in patients with ulcerative colitis are toxic megacolon which is refractory to medical management, a fulminant attack refractory to medical management, and uncontrolled colonic bleeding. [1][2][3]
Maintenance therapy Life-long maintenance therapy is recommended for all patients with extensive disease and patients with distal disease who relapse more than once a year. Oral aminosalicylates are first-line agents. Sulfasalazine has a higher incidence of side-effects, but should be considered in patients with co-existent arthropathy. Patients who frequently relapse despite aminosalicylate drugs are treated with thiopurines. No specific diet restrictions are required. [1][2][3]
References
  1. MARCHIONI BEERY R, KANE S. Current approaches to the management of new-onset ulcerative colitis Clin Exp Gastroenterol [online] :111-132 [viewed 23 July 2014] Available from: doi:10.2147/CEG.S35942
  2. PARRAY FQ, WANI ML, MALIK AA, WANI SN, BIJLI AH, IRSHAD I, NAYEEM-UL-HASSAN. Ulcerative Colitis: A Challenge to Surgeons Int J Prev Med [online] 2012 Nov, 3(11):749-763 [viewed 23 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3506086
  3. ESTEVE M, GISBERT JP. Severe ulcerative colitis: At what point should we define resistance to steroids? World J Gastroenterol [online] 2008 Sep 28, 14(36):5504-5507 [viewed 23 July 2014] Available from: doi:10.3748/wjg.14.5504
  4. NAVANEETHAN U, SHEN B. Pros and Cons of Medical Management of Ulcerative Colitis Clin Colon Rectal Surg [online] 2010 Dec, 23(4):227-238 [viewed 23 July 2014] Available from: doi:10.1055/s-0030-1268249