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Classification of Ulcerative Colitis by Disease Extent (Montreal Classification) | USMLE Step 2 CK

The Montreal Classification of ulcerative colitis (UC) provides a structured method to categorize the disease based on anatomical extent as seen on endoscopy, which is essential for diagnosis, treatment planning, and prognostic assessment. This classification is frequently tested on USMLE Step 2 CK, as it helps guide both clinical decision-making and therapeutic escalation in inflammatory bowel disease (IBD) management.

Ulcerative Proctitis (E1):
In E1, the inflammatory process is limited to the rectum. Patients typically present with rectal bleeding, urgency, and tenesmus due to inflammation in the distal colon. This subtype often spares systemic symptoms and responds well to topical therapies such as mesalamine suppositories or corticosteroid enemas, which directly target the rectal mucosa.

Left-sided Ulcerative Colitis (E2):
In E2, inflammation extends from the rectum up to the splenic flexure, involving the descending colon. Patients often report bloody diarrhea, mucus discharge, and left lower quadrant abdominal pain. Treatment typically includes a combination of oral and topical 5-aminosalicylic acid (5-ASA, e.g., mesalamine), and moderate to severe cases may require oral corticosteroids or immunomodulators like azathioprine or 6-MP.

Extensive Ulcerative Colitis (E3):
E3 involves colonic inflammation proximal to the splenic flexure, potentially affecting the entire colon (pancolitis). These patients may present with more severe symptoms, including frequent bowel movements, diffuse abdominal pain, weight loss, and systemic manifestations like fever or fatigue. Management includes high-dose corticosteroids for acute flares, and long-term therapy with immunomodulators (e.g., azathioprine) or biologic agents (e.g., anti-TNF drugs like infliximab), especially in refractory or steroid-dependent cases.

On USMLE Step 2 CK, you must recognize the extent-based classification (E1–E3), correlate it with clinical presentation, and identify appropriate treatment strategies for each type. Also, be aware that extent of disease is associated with risk of complications, including colorectal cancer in patients with long-standing extensive colitis.

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