ulcerative cholitis Flashcards
definition
- chronic
- inflammatory disease
- relapsing-remitting
- affects the colonic mucosa
- primarily affects large bowel
- extend to part of colon - left-hand-side colitis
- or entire colon - pancolitis
- doesnt spread beyond ileocaecal valve or small bowel
Mostly found in the rectum and can spread to the proximal parts of the colon. Can be found in the terminal ilium in those with extensive colitis
catagorised as + nmemonic
CLOSEUP
C - continuous inflammation
L - limited to colon and rectum
O - only superficial mucosa affected
S - smoking is protective
E - excrete blood and mucus
U - use aminosalicytes
P - primary sclerosing cholangitis
epidemiology
- Most common cause of IBD
- F>M
- Bimodal peak (15-25 and 55-65)
Aetiology
Genetic: Polygenic disease
- Jewish population
- family history of UC
Immunity:
- abnormal immunological response to intestinal microflora
Environmental :
- Smoking is protective in UC
- Milk consumption
- Bacterial microflora alteration
- Medications
- NSAIDS
- OCP - oral contraceptive pill
physiological changes in colon
Rectum is affected first
Extends proximally
Macroscopic changes:
- Evidence of continuous inflammation
- Mucosal surface appears red and inflamed
- May be evidence of polyps
Microscopic changes:
- Crypt abscesses
- Goblet cell depletion
- Increased inflammatory infiltration into lamina propria
clinical manifestations
Key presentation:
Rectal bleeding
Bloody diarrhoea
tenesmus or urgency
cramp pain in left iliac fossa
signs
Febrile - having, or showing the symptoms of having a fever
Pale
Dehydrated
Abdominal tenderness
Abdominal distension/mass
Tachycardic, hypotensive
symptoms
Weight loss
Fatigue
Abdominal pain
Loose stools
Rectal bleeding
Tenesmus (incomplete emptying)
Urgency
extra colonic involvement
eyes + mouth:
- uveitis
- episcleritis
- apthous ulcers
hepatobilliary:
- primary sclerosing cholangitis
joints + skin:
- ankylosing spondylitis
- arythra nodosum
gold standard / diagnosis
endoscopy with biopsy
1st line tests
- Bloods - can see anaemia and other signs
- ESR/CRP
- faecal calprotectin
<100µg/g = IBD is unlikely
100 – 250µg/g = Intermediate result – Repeat the test in 2 weeks
>250µg/g = Likely IBD refer to secondary care - ECG - Potential AF
- P-ANCA - Positive
other tests
Imaging
Abdo Xray - looking for dilations
Small bowel: diameter > 3cm
Large bowel: diameter > 6cm
Caecum: diameter > 9cm
grading of UC
truelove and witts
severity of UC in adults
Mild:
- < 4 bowel motions per day
- Small amount of blood
- no temperature
- no bpm>90
- no anaemia
- ESR </=30
Moderate:
- 4-6 bowel motions per day.
- Quantity of blood between mild and severe
- no temperature
- no pulse >90bmp
- no anaemia
- ESR </=30
Severe:
- > 6 bowel motions per day.
- Visible blood
- temperature >37.8
- pulse >90
- anaemia <10g/100mL
- ESR >30
management
inducing remission:
Mild-Moderate:
USE TOPICAL FIRST THEN IF DOESNT WORK USE ORAL
- 1st Line
Aminosalicylate (5-ASA) - eg mesalazine oral or rectal
- 2nd Line
Corticosteroids - eg prednisolone
- oral tacrolimus
Severe:
- 1st Line
IV Corticosteroids - eg hydrocortisone
- 2nd Line
- IV Cyclosporin -
Calcineurin inhibitor - important in T lymphocyte functioning
IV and levels need to be monitored
Unlikely to work if been on thiopurines
Maintenance Therapy:
- Aminosalicylate - eg mesalazine oral or rectal
- Azathioprine
- Mercaptopurine
- Biologics -
TNF-α Inhibitors - Infliximab and adalimumab
Alpha-4/beta-7 integrin inhibitor - Vedolizumab
JAK Inhibitor - tofacitinib
surgery
- 1/5
- As UC typically affects the colon and rectum a panprotocolectomy will remove the disease
Leaves either:
- An ileostomy
- Ileo-anal anastomosis (J pouch) - ileum folded back in itself and fashioned into a larger pouch that functions a bit like a rectum, then attached to the anus and collects stools prior to passing the motion
Complications
Toxic mega colon
Toxic, non-obstructive, dilation of the colon
Colorectal Cancer
25% of patients also develop extra-colonic manifestations during their lifetime
Acute severe ulcerative colitis - life threatening and requires high dose IV steroids
imaging / invasive testing
- AXR - lead pipe colon
- colonoscopy - continuous inflammation from rectum - doesnt go beyong mucosa, loss of haustral markings + pseudopolyps
- biospsy - loss of goblet cells, crypt absecess + inflammatory cells
- barium enema - lead piping inflammation, thumb printing, pseudopolyps
patient with severe symptoms - not responding - history of UC
toxic megacolon
refer for abdominal ct to diagnose
perform DR ABC and administer IV fluids
trulove and witts criteria for anaemia severe
<105
primary sclerosing cholitis
- fibrosis and narrowing of bile ducts
- ~80% of PSC patients have UC
- Causes bile duct inflammation, fibrosis, and strictures, leading to cholestasis.
LFTs:
- ↑ ALP, ↑ GGT (cholestatic pattern).
- Mildly ↑ ALT/AST.
- ↑ Bilirubin (late-stage disease or cholangitis).
Diagnosis: MRCP (beaded bile duct appearance), p-ANCA positive.
test to image toxic mega colon
Plain abdominal radiograph
which symptom is more suggesting of IBD than IBS
passing blood w stool
testing differences in acute flare
to avoid risk of perforation, wait until flare goes down for full colonoscopy - instead do just a plexible unprepared sigmoidoscopy
blurred vision, photophobia, pain in eye, red and tearful, small pupil
anterior uveitis
cycloplegic mydriatic drops - such as cyclopentolate
what indicated toxic megacolon and what should you do to investigate
- woresening abdominal distension
- pain
- urgent assessment with abdominal xray
pruritis (itch) and deranged LFTs indication and investigation
indicates primary sclerosis cholitis
- magnetic renonance cholangiopancreatography
first-line investigation toxic mega colon
plain abdominal xray
- shows marked colon dilation >6cm
- signs of pneumotatis intenstinals or free air is perforated
abnormal liver enzymes and weight loss
biliary tract carcinoma
bc increased risk on those with primary sclerosing cholangitis in UC
best investigation to investigate underlying UC cause in those suspected of having IBD
flexible sigmoidoscopy without proliferation
management of toxic megacolon
urgent colonic decompression through nasogastric tube insertion to prevent perforation
what prophylaxis to prescribe during severe flare
low molecular weight heparin
Ca 19-9
gene in those with cholangiocarcinoma
ulcerative cholitis
Magnetic resonance cholangiopancreatography shows beading of the bile ducts diagnosis and treatment
primary sclerosis cholitis
liver transplant
indication for an emergency panproctocolectomy
- not responding to IV fluids in 72 hours
environmental aetiology
- milk consumption
- bacterial microflora alteration
- medications
- NSAIDs
UC surgery curative?
yes can be
surgeries available
panprotocolectomy
leaves either:
ilieostomy - where whole colon is removed
ileo-anal anastomosis (J pouch) - ileum folded back into itself and fashioned back into a larger pouch which functions like a rectum - this is then attached to the anus and collects stools prior to passing the motion
