IBD- Ulcerative Colitis

Question 1

What is IBD?

Answer 1

Involves recurrent episodes of inflammation in the GIT, the two main types are ulcerative colitis and Crohn’s. They are associated with periods of exacerbation and remission.

Question 2

What are the risk factors for IBD?

Answer 2

• Genetics
• Environment
• Gut microbiome
• Typical patient presents in their 20s

Question 3

What are the general presenting features of IBD?

Answer 3

• Diarrhoea
• Abdominal pain
• Rectal bleeding
• Fatigue
• Weight loss

Question 4

What are the differentiating factors of Crohn’s?

Answer 4

NESTS

• N- No blood or mucus (PR (rectal) bleeding is less common)
• E- entire GIT affected (from mouth to anus)
• S- skip lesions on endoscopy
• T- terminal ileum most affected and Transmural (full thickness)
• S- smoking is a risk factor
• Crohn’s is also associated with strictures and fistulas

Question 5

What are the differentiating factors of ulcerative colitis?

Answer 5

CLOSEUP
- C- continuous inflammation
- L- limited to colon and rectum
- O- only superficial mucosa affected
- S- smoking may be protective (UC is less common in smokers)
- E- Excrete blood and mucus
- U- use amino salicylates
- P- Primary sclerosing cholangitis

Question 6

What are some other associated conditions that can present with IBD?

Answer 6

• Erythema nodosum
• Pyoderma gangrenosum (rapidly enlarging, painful skin ulcers )
• Enteropathic arthritis (a type of inflammatory arthritis)
• Primary sclerosing cholangitis (chronic liver disease in which the bile ducts inside and outside the liver progressively decrease in size due to inflammation and fibrosis- particularly seen with UC)
• Redeye conditions (episcleritis, scleritis and anterior uveitis)

Question 7

Who is UC more common in?

Answer 7

• in females
• ages 15-25
• ages 55-65

Question 8

What are the causes of UC?

Answer 8

1) immunity- an abnormal immunological response to intestinal microflora

2) Genetics- UC is a polygenic disease (genetic disorder caused by the combined action of more than one gene)

3) Environmental- Smoking is protective in UC, and vice versa in CD. Milk consumption, bacterial microflora alteration and medications (NSAIDs, OCP) are linked with UC.

Question 9

What are the three types of UC, and what percentage of patients have it?

Answer 9

1) Proctitis- inflammation of the anus and the lining of the rectum, affecting only 6 inches of the rectum. About 50% of patients suffer from this, however about 1/3rd of these patients will develop more proximal disease.

2) Left-sided colitis- affects the left side of the colon. About 30% of the patients suffer from this.

3) Pancolitis- inflammation of the entire colon.- about 20% of the patients.

Question 10

What is backwash ilietis?

Answer 10

Refers to the reflux of colonic contents into the distal few centimetres of the ileum through the ileocecal valve. Backwash ileitis can make the distinction between UC and CD more difficult.

Question 11

What are the macroscopic and microscopic changes seen in UC?

Answer 11

Macroscopic:
- red inflammed mucosa
- continuous inflammation
- friable
- inflammatory polyps

Microscopic:
- Goblet cell depletion
- Crypt abscesses
- Inflammatory infiltrate in lamina propria

Question 12

What are the signs and symptoms of UC?

Answer 12

Symptoms:
- Weight loss
- Fatigue
- Abdominal pain
- Loose stools
- Rectal bleeding
- Tenesmus (incomplete emptying)
- Urgency

Signs:
- Febrile (showing signs of fever)
- Pale
- dehydrated
- abdominal tenderness
- abdominal distention/mass
- tachycardic, hypotensive

Question 13

What is a major complication of UC?

Answer 13

Toxic mega colon- medical emergency, which refers to toxic, non-obstructive, dilatation of the colon (more than 6 cm). Patients with UC who present with abdominal distension and tenderness should be admitted for suspected TMC.

Question 14

What are other features that suggest TMC?

Answer 14

• fever
• tachycardia
• hypotension
• dehydration
• altered mental status
• biochemical abnormalities (leucocytosis, anaemia, and electrolyte derangements)

Question 15

What are some extra-colonic manifestations of UC?

Answer 15

Musculoskeletal:
- Arthritis
- Osteopeania/Osteoporosis
- clubbing of hands and feet

Eyes, mouth & skin:
- uveitis (may be divided into anterior, intermediate and posterior)
- episcleritis (superficial inflammation of the sclera)
- Mouth- apthous ulcers (recurrent mouth ulcers)
- Skin- erythema nodosum- painful, purple nodules on the anterior aspects of the shins

Hepatobiliary:
- fatty liver disease
- autoimmune liver disease
- most common pathology- primary sclerosing cholangitis- chronic liver disease in which the bile ducts inside and outside the liver progressively decrease in size due to inflammation and fibrosis. Note: PSC should be suspected in any UC patient who has isolated rise in ALP.

Hematological :
- anaemia
- thromboembolism

Question 16

How do you diagnose UC?

Answer 16

• macroscopic assessment (endoscopy)
• Histological evidence (biopsy)

Question 17

What investigation would you do for UC?

Answer 17

Bedside:
- observations
- ECG
- Urinalysis
- Stool microscopy, culture & sensitivities
- Ova, cysts and parasites
- C.diff toxin
- Faecal calprotectin (marker of intestinal inflammation)

Bloods:
- Full blood count
- Liver function tests
- Urea & electrolytes
- CRP
- Arterial/venous blood gas
- Haematinics
- Magnesium
- Clotting
- Autoantibodies (e.g. p-ANCA)

Imaging:
- abdominal X-rays- to look for diltations and perforations of the bowel
- CT can be performed where there is concern regarding complications (toxic megacolon) and prior to surgery.

Endoscopy:
- colonoscopy
- biopsies can be taken for further investigation
- sigmoidoscopy

Question 18

Using which system can the severity of UC be assessed?

Answer 18

Truelove & Witts’ Classification.

1) Mild
< 4 bowel motions per day.
Small amount of blood.

2) Moderate
4-6 bowel motions per day.
Quantity of blood between mild and severe.

3) Severe
> 6 bowel motions per day.
Visible blood
Systemic upset

Question 19

How do you manage UC by inducing remission?

Answer 19

Induce remission:
- patients presenting with UC for the first time, or those who develop flare of UC- Aminosalicylates (5-ASA) and/or steroids

• In patients with mild/moderate UC, 5-ASA (topically +/- orally)
• Patients with extensive UC (Pancolitis or left-sided colitis)- should be treated with both oral and topical 5-ASAs (enemas)
• patients with proctitis- can be treated with 5-ASA suppositories alone

Note: Patients who fail to respond to maximum dose of 5-ASA agents, or those with moderate-to-severe UC, can be treated with the addition of systemic corticosteroids as a 6-8 week weaning course. Steroid enemas can also be added. If patients do not respond to steroids over a two week course then hospital admission and biologics can be considered.

Question 20

What is the maintenance therapy for UC?

Answer 20

• thiopurines (azathioprine & mercaptopurine)
• biologics

Question 21

How does the maintenance therapy work and who are they given to usually?

Answer 21

Thiopurines (azathioprine and mercaptopurine): work through purine synthesis inhibition in lymphocytes leading to immunosuppression. Must check TPMT enzyme activity before use. Homozygous mutations in TPMT can lead to dangerous bone marrow suppression. Major side-effects include pancreatitis and hepatotoxicity.
Biologics: refers to monoclonal antibodies. Options include infliximab/adalimumab (tumour necrosis factor alpha inhibitors), vedolizumab (alpha-4/beta-7 integrin inhibitor) and tofacitinib (JAK inhibitor). More biologic agents are being tested in clinical trials

Question 22

What are the other ways in which UC is managed? Who are they indicated in?

Answer 22

• Surgical intervention- The principle surgical option in UC is proctocolectomy followed by ileal pouch anal anastomosis (IPAA) or end ileostomy. Surgery may be indicated in patients with acute severe ulcerative colitis that has failed to respond to medical therapy, patients who develop complications (e.g. malignancy, perforation), or those with chronic active symptoms despite optimal medical therapy.
• Surveillance Colonoscopy- Currently, patients with IBD in the UK are offered surveillance colonoscopy between 6-10 years following diagnosis to screen for dysplasia (abnormal cell growth, predisposes to malignancy) Patients with primary sclerosing cholangitis (PSC) are at a particularly high risk of cancer.

Question 23

What is acute severe ulcerative colitis?

Answer 23

a life-threatening condition that requires high-dose intravenous steroids.

Question 24

What are the initial assessments of a patient with suspected acute severe UC?

Answer 24

• inpatient admission
• Bloods- FBC, CRP, U&E, LFT, Mg +/- pre-biologic screening (a series of blood test that are needed to ensure it is safe to give a monoclonal antibody that suppresses the immune system)
• Faeces cultures- Stool MC&S, OCP (Ova, cysts, parasites), C.diff toxin, stool virology (norovirus)
• imaging- abdominal x-ray or CT
• inpatient lower GI endoscopy- sigmoidoscopy to assess disease activity

Question 25

What is the initial treatment for acute severe UC patients?

Answer 25

• High dose corticosteroids (IV hydrocortisone 100 mg QDS) with PPI (for gastric protection)
• VTE Prophylaxis- low molecular weight heparin unless counterindicated
• antibiotic- start with broad spectrum
• hydration and nutrition

Question 26

What do you do if patients with acute severe UC fail to respond to treatment within 72 hours?

Answer 26

Rescue therapy should be considered, options include:
- Ciclosporin- calcineurin inhibitor, unlikely to work if patient has been on thiopurines previously
- infliximab- can be combined with thiopurines. contraindications include latent TB, demyelination and active sepsis.
- surgical intervention- should be considered in patients not responding to medical therapy within seven days or development of complications such as toxic mega colon, perforation.