Inflammatory bowel disease: Ulcerative colitis Flashcards
What is ulcerative colitis?
Ulcerative colitis (UC) is a form of inflammatory bowel disease.
Where does inflammation start in ulcerative colitis?
Inflammation always starts at the rectum and is continuous.
What is the peak incidence age for ulcerative colitis?
The peak incidence is in people aged 15-25 years and 55-65 years.
What are common initial symptoms of ulcerative colitis?
Symptoms include bloody diarrhoea, urgency, tenesmus, and abdominal pain, particularly in the left lower quadrant.
What is the preferred method for diagnosing severe colitis?
In severe colitis, flexible sigmoidoscopy is preferred over colonoscopy due to the risk of perforation.
What are typical endoscopic findings in ulcerative colitis?
Typical findings include red, raw mucosa that bleeds easily, widespread ulceration with preservation of adjacent mucosa (‘pseudopolyps’), and inflammatory cell infiltrate in the lamina propria.
What are the barium enema findings in long-standing ulcerative colitis?
Findings include loss of haustrations, superficial ulceration, ‘pseudopolyps’, and a narrow and short colon (‘drainpipe colon’).
What are common extra-intestinal features of inflammatory bowel disease?
Common features include arthritis (pauciarticular, asymmetric), erythema nodosum, episcleritis, and osteoporosis.
Which extra-intestinal feature is most common in both Crohn’s disease and ulcerative colitis?
Arthritis is the most common extra-intestinal feature in both CD and UC.
What extra-intestinal features are unrelated to disease activity?
Unrelated features include polyarticular arthritis, uveitis, pyoderma gangrenosum, clubbing, and primary sclerosing cholangitis.
What is the risk of colorectal cancer in patients with ulcerative colitis?
The risk is significantly higher than that of the general population, although studies report widely varying rates.
The increased risk is mainly related to chronic inflammation.
What is the prognosis for patients with ulcerative colitis compared to those without?
Patients with ulcerative colitis have a worse prognosis than those without, partly due to delayed diagnosis.
What are the factors that increase the risk of colorectal cancer in ulcerative colitis patients?
Factors include disease duration > 10 years, patients with pancolitis, onset before 15 years old, unremitting disease, and poor compliance to treatment.
How should colonoscopy surveillance be determined in inflammatory bowel disease patients?
Colonoscopy surveillance should be decided following risk stratification.
What is the follow-up colonoscopy schedule for lower risk patients?
Lower risk patients should have a 5 year follow-up colonoscopy if they have extensive colitis with no active endoscopic/histological inflammation, left sided colitis, or Crohn’s colitis of <50% colon.
What is the follow-up colonoscopy schedule for intermediate risk patients?
Intermediate risk patients should have a 3 year colonoscopy if they have extensive colitis with mild active endoscopy/histological inflammation, post-inflammatory polyps, or a family history of colorectal cancer in a first degree relative aged 50 or over.
What is the follow-up colonoscopy schedule for higher risk patients?
Higher risk patients should have a 1 year follow-up colonoscopy if they have extensive colitis with moderate/severe active endoscopic/histological inflammation, a stricture in the past 5 years, dysplasia in the past 5 years declining surgery, primary sclerosing cholangitis, transplant for primary sclerosing cholangitis, or a family history of colorectal cancer in first degree relatives aged <50 years.
What are common factors linked to ulcerative colitis flares?
Stress, medications, NSAIDs, antibiotics, and cessation of smoking.
How are flares of ulcerative colitis classified?
Flares are classified as mild, moderate, or severe.
What characterizes a mild ulcerative colitis flare?
Fewer than four stools daily, with or without blood; no systemic disturbance; normal erythrocyte sedimentation rate and C-reactive protein values.
What characterizes a moderate ulcerative colitis flare?
Four to six stools a day, with minimal systemic disturbance.
What characterizes a severe ulcerative colitis flare?
More than six stools a day, containing blood; evidence of systemic disturbance such as fever, tachycardia, abdominal tenderness, distension or reduced bowel sounds, anaemia, and hypoalbuminaemia.
What should be done for patients with evidence of severe ulcerative colitis?
Patients with evidence of severe disease should be admitted to hospital.
What are the two main treatment phases for ulcerative colitis?
Treatment can be divided into inducing and maintaining remission.
What classification is used for the severity of ulcerative colitis?
The severity of UC is classified as mild, moderate, or severe.
What defines mild ulcerative colitis?
Mild: < 4 stools/day, only a small amount of blood.
What defines moderate ulcerative colitis?
Moderate: 4-6 stools/day, varying amounts of blood, no systemic upset.
What defines severe ulcerative colitis?
Severe: >6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers).
What is the first-line treatment for mild-to-moderate proctitis?
Topical (rectal) aminosalicylate: rectal mesalazine is superior to rectal steroids and oral aminosalicylates.
What should be done if remission is not achieved in mild-to-moderate proctitis within 4 weeks?
Add an oral aminosalicylate.
What is the treatment for proctosigmoiditis and left-sided ulcerative colitis if remission is not achieved within 4 weeks?
Add a high-dose oral aminosalicylate OR switch to a high-dose oral aminosalicylate and a topical corticosteroid.
What is the treatment for extensive disease if remission is not achieved within 4 weeks?
Stop topical treatments and offer a high-dose oral aminosalicylate and an oral corticosteroid.
How should severe colitis be treated?
Severe colitis should be treated in hospital with IV steroids as first-line.
What should be considered if there is no improvement after 72 hours of treatment for severe colitis?
Consider adding IV ciclosporin to IV corticosteroids or consider surgery.
What is the maintenance treatment following a mild-to-moderate ulcerative colitis flare?
Topical (rectal) aminosalicylate alone or an oral aminosalicylate plus a topical (rectal) aminosalicylate.
What is the maintenance treatment for left-sided and extensive ulcerative colitis?
Low maintenance dose of an oral aminosalicylate.
What is recommended following a severe relapse or >=2 exacerbations in the past year?
Oral azathioprine or oral mercaptopurine.
Is methotrexate recommended for the management of ulcerative colitis?
Methotrexate is not recommended for the management of UC.
What evidence exists regarding probiotics in ulcerative colitis?
There is some evidence that probiotics may prevent relapse in patients with mild to moderate disease.
