Inflammatory bowel disease - Ulcerative Colitis

Question 1

Definition

Answer 1

Autoimmune colitis = relapsing remitting inflammatory disorder of the colonic mucosa
Associated with HLA B27 gene + PANCA

Question 2

Microscopic and Macroscopic Characteristics

Answer 2

Macro:
- Only colon affected
- Starts at rectum, can progress as far as ileocaecal valve
- Circumferential and continuous inflammation
- Ulcers and pseudo polyps in severe disease
Micro:
- Inflammation confined to mucosa only
- Crypt abscesses
- Depleted goblet cells

Question 3

Epidemiology

Answer 3

Jewish people
Caucasian - Northern European + Northern America
Affects males and females equally
Bimodal age = 15-20 , 50 +

Question 4

Risk factors

Answer 4

Family history
HLA B27
Non-smoker (SMOKING = PROTECTIVE)

Question 5

Aetiology

Answer 5

Not well understood, theories including polygenic predisposition, environmental factors, and immune dysfunction

Question 6

Pathophysiology

Answer 6

C - Continuous inflammation
L - Limited to colon + rectum
O - Only superficial mucosa affected
S - Smoking protective
E - Excrete blood and mucus
U - Use amino salicylates
P - Primary Sclerosing Cholangitis
Inflammation involves the rectum which extends proximally to affect a variable length of continuous colon - never spreads beyond ileocaecal valve = confined to large bowel + does not affect anus

Question 7

Signs

Answer 7

Pain in LLQ + TENESMUS (RECTAL DEFECATION PAIN)
Bloody mucusy watery diarrhoea
Fever

Question 8

Symptoms

Answer 8

Diarrhoea
Blood and mucus in stool
Urgency
Abdo pain (LLQ)
Weight loss + malnutrition

Question 9

Extra intestinal manifestations

Answer 9

• Uveitis
• Pyoderma gangrenosum/Erythema nodosum
• Arthritis - Spondyloarthropathies
• Primary sclerosing cholangitis

Question 10

Investigations

Answer 10

FIRST LINE =
- P-ANCA
- Raised WCC, platelets
- Anaemia
- Raised CRP/ESR
Stool test =
- Faecal calprotectin raised (non-specific)
GOLD STANDARD = Colonoscopy and Biopsy
- Continuous, lead pipe sign
- Mucosal inflammation with crypt hyperplasia
- Absence of granulomas

Question 11

Scoring scale for severity of flares

Answer 11

TRUE LOVE + WITTS

Question 12

Treatment

Answer 12

1. Flares = 5-ASA (amino salicylic acid) SULFASALAINE (FIRST LINE) or PREDNISOLONE (SECOND LINE IF SEVERE)
   - mesalazine rectal = rectal suppository for proctitis
2. Remission = AZANTHIOPRINE, CICLOSPORIN
3. Biologics = Anti-TNF a : INFLIXIMAB
   Surgery = total/partial colectomy = CURATIVE

Question 13

Complication

Answer 13

Toxic megacolon
Rapid progression to bowel cancer skipping polyps step