Gastro - Ulcerative colitis Flashcards
what is UC?
Autoimmune chronic inflammation of the colon that may be triggered by colonic bacteria causing GI tract inflammation.
what is the course of UC?
life-long, relapsing-remitting
which part of the bowel does UC affect?
Limited to colon:
- proctitis (confined to rectum)
- proctosigmoiditis (rectum + sigmoig colon)
- left-sided colitis (rectum to splenic flexure)
- extensive colitis (rectum to hepatic flexure)
- pancolitis (all colon)
name 2 microscopic features of UC
- abnormal crypt architecture, inc. crypt abscesses
2. chronic inflammatory infiltration of lamina propria
name 3 macroscopic features of UC
- loss of haustra (featureless mucosal view)
- widespread irregular superficial ulceration
- pseudopolyps
suggest possible abdo signs and symptoms of UC
Symptoms:
- bloody diarrhoea
- colicky abdo. pain (esp. during diarrhoeal episodes)
- urgency or tenesmus
Signs:
- tenderness
- weight loss
suggest possible extra-abdo features of UC
- systemic Sx: fever, malaise
- eyes: iritis, uveitis, episcleritis
- skin: erythema nodosum, pyoderma gangrenosum
- liver: primary sclerosing cholangitis, hepatitis
- joints: inflammatory arthritis, ankylosing spondylitis
which investigations would you perform on a pt with suspected UC?
Bloods:
- FBC: may show anaemia
- ESR/CRP: inflammation markers, indicate severity
- UandEs and LFTs
- iron studies, vitB12 and folate
- serological markers: p-ANCA more common in UC, ASCA more common in CD
- coeliac screen: total IgA and IgA tTG to rule out coeliac disease
Bedside tests:
- faecal calprotectin: to detect colonic inflammation and rule out functional diarrhoea
- microbiological stool testing: for C. diff toxin and other pathogens, inc. ova, cysts and parasites
- sigmoidoscopy +/- rectal biopsy: considered in all pts with diarrhoea
Imaging:
- AXR: to exclude colonic dilatation and perforation, may help assess disease extent or ID proximal constipation
- colonoscopy + biopsies: 1st line for Dx of colitis, with at least 2 biopsies from 5 diff sites
which UC features may be seen on AXR?
lead-pipe colon
which UC features may be seen on colonoscopy?
- loss of definition
- continuous superficial ulceration with friable mucosa
describe the UC severity index
- mild: <4 stools/day, no more than small amounts of blood in stool, no anaemia, HR <90, no fever, normal ESR and CRP.
- moderate: 4-6 stools/day with more blood, no anaemia, HR <90, no fever, normal ESR and CRP.
- severe: >6 stools/day with visible blood in stools, and at least 1 feature of systemic upset (Temp >37.8, HR >90, anaemia, ESR >30)
which drugs would you suggest to induce remission in mild-moderate UC?
- Proctitis/proctosigmoiditis
- topical and/or oral aminosalicylate (topical or combination therapy work better) - left-sided and extensive UC
- oral and/or topical aminosalicylate OR oral aminosalicylate + oral beclometasone
If no improvement after 4wks of above, add oral prednisolone. If no response after 2-4 wks, add oral tacrolimus.
what management would you suggest to induce remission in acute severe UC?
i. IV corticosteroids
If contra-indicated/no improvement within 72 hrs, add ciclosporin or consider surgery.
what management would you suggest to maintain UC remission?
- 1st line - proctitis/proctosigmoiditis: topical +/- oral aminosalicylate
- 1st line - L-sided/extensive UC: low maintenance dose oral aminosalicylate
- 2nd line - add oral azathioprine or mercaptopurine if 2+ corticosteroid courses required/yr, disease relapses when dose of prednisolone <15 mg/day or disease relapses within 6 wks of stopping steroids
describe a possible type of surgery for UC
restorative protocolectomy with ileal pouch-anal anastamosis (curative)
