Ulcerative Colitis in Children Workup

Updated: Jul 26, 2019
  • Author: Judith R Kelsen, MD; Chief Editor: Carmen Cuffari, MD  more...
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Approach Considerations

Endoscopy must be performed if ulcerative colitis (UC) is suspected. A full colonoscopy is always indicated. As a result, going directly to colonoscopy is more cost-effective in many cases. [6]

Antineutrophil cytoplasmic antibodies (ANCA) and anti–Saccharomyces cerevisiae antibodies (ASCA) have been the most intensely studied serologic markers for inflammatory disease.

Other studies include complete blood count, stool assays, comprehensive metabolic profile, an upper gastrointestinal series with small bowel follow through, and abdominal obstruction series.

See also the Guidelines section for recommendations by the American College of Gastroenterology and the American Gastroenterological Association.



An upper endoscopy and colonoscopy are performed. Wireless video capsule endoscopy, also known as the Pillcam, is an increasingly used imaging technology that may reveal small bowel involvement in inflammatory bowel disease that differentiates Crohn disease from ulcerative colitis.

Proceeding directly to full colonoscopy may be especially applicable in young children, in whom flexible sigmoidoscopy is likely to necessitate the same degree of sedation as is used with colonoscopy. A flexible sigmoidoscopy is never indicated in the pediatric population for diagnostic purposes unless severity of disease prevents passage to the terminal ileum. One must visualize the whole colon to determine the extent of disease.

Go to Rigid Sigmoidoscopy for more complete information on this topic.



Colonoscopy with biopsy is the most valuable procedure in the evaluation of the patient with inflammatory bowel disease. Typical findings in someone with ulcerative colitis (UC) are inflammation that is first evident in the rectum and that proximally extends in a contiguous fashion. The mucosa typically appears erythematous, friable, and granular and has lost the normally visible vascular markings. Findings more consistent with Crohn disease (CD) than with UC are sparing of the rectal mucosa, aphthous ulceration, and noncontiguous or skip lesions.

When possible, visualizing the entire colon and the last portion of the ileum (terminal ileum) is optimal, because the terminal ileum is not actively involved in UC but is commonly involved in CD. Nevertheless, patients with pancolitis occasionally have microscopic inflammation in the terminal ileum, which is thought to be secondary to reflux of colonic contents through an inflamed ileocecal valve (ie, backwash ileitis). [7]  

Biopsy findings consistent with UC are polymorphonuclear leukocytes near the base of the crypts. Cryptitis describes aggregation of polyps in the crypt epithelium, and the term crypt abscess is used when polyps have accumulated in the lumen of the crypt.

Lymphocytes, eosinophils, and mast cells may also be observed in the lamina propria in acute UC. No pathognomonic biopsy findings have been described for UC, however. Noncaseating granulomas are diagnostic of CD.

Go to Colonoscopyfor more complete information on this topic.


Serologic Markers for Inflammatory Disease

Serologic markers can provide more information; however, these alone are not diagnostic of inflammatory bowel disease (IBD) and lack accuracy to direct clinical care. [8]

Antineutrophil cytoplasmic antibody (ANCA) test is most commonly associated with ulcerative colitis (UC). ANCA assay results are positive in 60-80% of UC patients. The finding of ANCA is roughly 50% sensitive and 94% specific, and it has a 76% positive predictive value for UC. [9, 10, 11] ANCA is present in only about 40% of patients with Crohn disease.

Specifically, perinuclear ANCA (pANCA), found on the inside of the nuclear membrane, is highly associated with UC. The presence of pANCA is associated with an earlier need for surgery.

For children with ambiguous and mild complaints and for whom UC is part of the differential diagnosis, algorithms have been proposed in which the presence of ANCA is used to identify those patients who require more invasive diagnostic tests. [12]  

Anti-S cerevisiae antibody (ASCA) test is a serologic marker that is more highly associated with Crohn disease, being present in 60% of cases; ASCA is present in only 12% of UC patients.

ANCA and ASCA titers are not correlated with disease activity. [13]


Laboratory Studies

Complete blood cell (CBC) count

A CBC count commonly reveals a mild anemia, which can be due to chronic blood loss (ie, microcytic, hypochromic) or may represent chronic disease (ie, normocytic). In cases of fulminant colitis, severe anemia may be present. The CBC discloses the hematocrit level, which may be decreased in children with chronic disease or acute bleeding.

Metabolic panel

Obtain a comprehensive metabolic panel. Serum albumin levels may be low in fulminant colitis.


Erythrocyte sedimentation rate (ESR) and C-reactive protein level are frequently elevated during active disease. Micronutrient and vitamin levels are typically low in Crohn disease but less commonly so in ulcerative colitis. Liver dysfunction may indicate sclerosing cholangitis or autoimmune hepatitis.


Stool Assays

Obtain stool cultures to rule out infectious colitis. Obtain an assay for E coli H7:0157 if the patient's symptoms are consistent with hemolytic-uremic syndrome.

Obtain a stool assay for C difficile toxins A and B, because C difficile colitis can mimic ulcerative colitis, or it may be responsible for a flare. Evaluation for toxin A or toxin B alone is inadequate for an accurate diagnosis of C difficile infection.

The fecal calprotectin level may be elevated during times of active inflammation. Calprotectin is a calcium-binding S-100 protein found in the neutrophil cytosol that is released with cell activation or death. An assay for calprotectin is now commercially available and may be useful to differentiate a disease flare from other causes of abdominal pain or diarrhea.


Imaging in Ulcerative Colitis

In all children with ulcerative colitis (UC) except those with sepsis, imaging studies should be undertaken only if they are deemed necessary after endoscopic evaluation is complete.

Go to Ulcerative Colitis Imaging for more information on this topic.

Abdominal obstruction series

An abdominal obstruction series (ie, supine and upright abdominal radiography) is useful to evaluate for air-fluid levels, dilated loops of bowel, evidence of obstruction, or possible toxic megacolon. No pathognomonic findings for UC with this type of study have been reported.

Barium enema

Barium enema study is useful to evaluate the colon for stricture and for mucosal abnormalities, especially when colonoscopy cannot be performed. Barium enema studies may also demonstrate a source of bleeding other than UC, such as a polyp.

Upper gastrointestinal (GI) series

An upper GI series with small-bowel follow-through is used to evaluate for small-bowel inflammation that would support a diagnosis of Crohn disease (CD) rather than UC.

Computed tomography (CT) scanning

CT scanning of the abdomen is useful to evaluate for bowel-wall thickening and obstruction. If present, abscesses and fistulae imply a diagnosis of CD rather than UC. Many children with a preliminary diagnosis of inflammatory bowel disease undergo CT scanning of the abdomen as part of the initial evaluation of abdominal pain.

Nuclear imaging

Radionuclide-tagged white blood cell scanning can be used to demonstrate small-bowel inflammation that differentiates CD from UC.

Magnetic resonance imaging (MRI)

MRI of the abdomen is increasingly used to evaluate the large and small bowel for inflammatory changes and to look for transmural versus mucosal inflammation.

Video capsule

Video capsule endoscopy is used as another modality to distinguish CD from UC. The sensitivity of video capsule in diagnosing small bowel lesions is greater than that of barium radiography. [14]