Gastroenterology Flashcards
UC definition + areas affected
relapsing + remitting inflammatory disorder of the colonic mucosa.
1- proctitis- can affect just the rectum 30%
2- left-sided colitis - or distal colitis extend to involve part of the colon40%- rectal bleeding, urge/tenesmus
3- pancolitis- or total/entire colon 30%- chornic >6m diarrhoea
never spreads proximal to ileocaecal valve except for backwash ileitis
what is the suspected cause of UC?
inappropriate immune respones against ?abnormal colonic flora in genetically susceptible individuals
what is the pathology of UC?
pathological hallmarks: inflammation always present in rectum, continuous, limited to mucosa of bowel/superficial
hyperaemic/haemorrhagic colonic mucosa +/- pseudopolyps formed by inflammation
punctate ulcers may extend deep into lamina propria- inflammation is normally not transmural
continuation inflammation limited to mucosa differentiates it from Crohns disease
prevalence 100-200/100 000
at what age does UC typically present?
20-40yrs
what are the symptoms of UC?
episodic or chornic diarrhoea +/- blood + mucus
malaise
crampy abdominal discomfort
bowel frequency relates to severity (4 mild, 5 mod, 6 severe)
urgency/tenesmus- proctitis
systemic symptoms in attacks: fever, malaise, anoreaxia, decreased weight
what are the signs of UC?
typically none
in acute severe UC may be fever, tachycardia, tender distended abdomen
extraintestinal signs: eyes, skin, joints, other
1- eyes: uveitis, conjunctivitis, episcerltis, iritis
2- skin: erythema nodosum, pyoderma gangrenous
3- joints: large joint arthritis, sacroiliitis, ankylosing spondylitis
4- other: clubbing, aphthous oral ulcers, nutrional deficits, hepatitis, gallstones, primary biliary cirrhosis
what investigations would you do for UC?
blood tests: FBC, ESR, CRP, UE, LFT, blood culture
stool MCS/CDT- to exclude campylobacter, c. difficile, salmonella, shigella, e coli, amoebae
faecal calprotectin- GI inflammaton, high sensitivity
AXR- to exclude toxic dilatation
lower gI endoscopy - limited flexible sigmoidoscopy if acute to assess and biopsy, full colonoscopy once controlled to define disease extent
what is shown on AXR for UC?
no faecal shadows
mucosal thickening/islands
colonic dilatation
what are the acute complications of UC?
toxic dilatation of colon (mucosal islands, colonic diameter >6cm) with risk of perforation
venous thromboembolism- give prophylaxis to all inpatients regardless of rectal bleeding
decreased K+
what are the chronic complications of UC?
colonic cancer- risk related to disease extent and activity about 5-10% with pancolitis for 20yrs
neoplasms may occur in flat, normal-looking mucosa
so to spot precursor areas of dysplasia surveillance colonoscopy 1-5yrs depdnign on risk with multiple random biopsies or biopsies guided by differential uptake by abnomral mucosa of dye spreayed endoscopically
what is the treatment for mild UC?
goals are to induce then maintain disease remission
F-ASA eg mesalazine
- PR for distal disease 1g
- PO extensive disease 2g
- combined PR PO if flare
topical steroid foams PR eg hydrocortisone + prednisolone 20mg retention enemas added to PR 5-ASA if needed
what are the hallmarks of UC on rectal biopsy?
distortion of colonic crypts
depletion of goblet cell stores of mucus
what is the treatment for moderate UC?
induce remission with oral prednisolone 40mg/d for 1 week
taper by 5mg/week for next 7 weeks
then maintain on 5-ASA
what do you need to monitor when UC patient is on 5-ASA treatment?
FBC + U&Es at the beginning, then 3 months, then annually
what are the side effects of 5-ASA treatment?
rash haemolysis hepatitis pancreatitis paradoxical worsening of colitis
what is the treatment for severe UC?
if unwell + >6 motions/day admit
1- IV hydration/electrolyte replacement
2- IV steroids eg hydrocortisone 100mg/6h or methylprednisolone 40mg/12h
3- rectal steroids eg hydrocortisone 100mg in 100ml 0.9 saline/12h PR
4- thromboembolism prophylaxis
5- multiple stool MC&S/CDT to exclude infection
what investigations will you do to monitor someone who is admitted with severe UC?
1- monitor obs- temp, pulse, bp + record stool frequency/character
2- BD exam- distension, bowel sounds, tenderness
3- daily FBC, ESR, CRP UE +/- AXR. consider blood transfusion hb<80g/L
if someone is admitted with severe UC and on day 3-5 their CRP is >45 and stools >6/day what would you do? And what would you do if they worsen/improve?
rescue therapy with ciclosporin or infliximab
can avoid colectomy but involve surgeons early
if fails to improve by day 7-10 need urges colectomy
if improves- transfer to prednisolone pO 40mg/24h. schedule maintenace infliximab if used for rescue, or azathioprine if ciclosporin rescue
when would you move on to immunomodulation treatment in UC patients?
patient flare on steroid tapering or require >2 courses of steroids/year eg azathioprine 2-2.5mg/kg/d PO
30% pts develop SE requiring treatment cessation eg abdo pain, nausea, pancreatitis, leucopenia, abnormal LFTs
if UC patient is on immunomodulation therapy, what investigations would you do to monitor?
monitor FBC, UE, LFT weekly for 4 weeks
then every 4 weeks for 3 months
then at least 3-monthly
when would you put UC patients on biologic therapy?
if intolerant of immunomodulation or developing symptoms despite an immunomodulator
when does a UC patient need surgery? What type of surgery?
subtotal colectomy + terminal ileostomy for failure of medical therapy or fulminant colitis with toxic dilatation/perforation
subsequently completion proctectomy- permanent stoma
or ileo-anal pouch- but may get pouchitis- give abx metronidazole + ciprofloxacin for 2 weeks
What is the definition of Crohn’s disease?
a chronic inflammatory disease characterised by transmural granulomatous inflammation affecting any part of the gut from mouth to anus
especially terminal ileum in 70%
unaffected bowel between areas of active disease- skip lesions
what is the cause of CD?
inappropriate immune response against ?abnormal gut flora in genetically suspectible individuals
smoking increases risk x3-4, NSAIDs exacerbates
prevalence 100-200/100 000
