Ulcerative Colitis

Question 1

What is ulcerative colitis?

Answer 1

Inflammation of the LOWER GI tract including the colon (large intestine) and rectum resulting in ulceration and bleeding/pus

Question 2

Diagnostic symptoms

Answer 2

Bloody diarrhoea >6 weeks, rectal bleeding, faecal urgency, painful urge to pass stools, constipation, abdominal pain, fatigue, weight loss, family history

Question 3

Acute UC management (mild)

Answer 3

4-8 week course
1st line give topical aminosalicylate (suppository or enema)
If remission not achieved within 4 weeks add oral aminosalicylate
e.g. MESALAZINE and SULFASALAZINE

For induction of remission if not tolerated/ineffective consider oral corticosteroid e.g. prednisolone (taper down)

Question 4

Extensive UC management

Answer 4

1st line topical and oral aminosalicylate dual therapy

If fails after 2-4 weeks, add calcineurin inhibitor e.g TACROLIMUS or CYCLOSPORIN to oral corticosteroid

Question 5

Acute UC management (severe)

Answer 5

Medical emergency
1st = IV HYDROCORTISONE or METHYPREDNISOLONE

2nd = IV CICLOSPORIN

3rs = Biologic therapy (TNF-alpha monoclonal antibody agents)
e.g. IV INFLIXIMAB and SC ADALIMUMAB and GOLIMUMAB

Question 6

Why are aminosalicylates the drug of choice?

Answer 6

Single daily dosing

Suppositories and enemas preferred

Question 7

Add on therapy criteria

Answer 7

More than two exacerbations in 12-months that required corticosteroid therapy or if remission not maintained by aminosalicylate therapy

Question 8

Add on therapy

Answer 8

Immunosuppressants

e.g. AZATHIOPRINE or MERCAPTOPURINE (risk of non-melanoma skin cancer) or METHOTREXATE (2nd line)

Question 9

Diagnostic investigations

Answer 9

FBC - anaemia due to blood loss, malabsorption or malnutrition; increased platelet count suggests active inflammation

Elevated CRP - inflammatory marker and infection

U&Es - dehydration

LFTs - low serum albumin suggests protein-losing enteropathy and reflects disease activity/severity/nutrition

TFTs - want to exclude hypothyroidism

Ferritin, B12 and Vit D - nutritional deficiencies due to malabsoprtion or intestinal loss

Faecal calprotectin - white cell marker elevated suggests inflammation (normal levels in IBS)

Coeliac serology to exclude coeliac disease

Stool microscopy to exclude infective gastroenteritis or pseudomembranous colitis (c.diff +)

Question 10

Flare up management

Answer 10

Assess severity

Hospital if sever diarrhoea, fever/dehydration/hypotension/tachycardia, severe abdo pain, intestinal obstruction, BMI <18.5, raised inflammatory markers

Exclude differential diagnosis e.g. C.diff

Check drug adherence

Prescribe short course oral corticosteroid as per shared care agreement

Do NOT prescribe NSAID if suspected SEVERE colitis

Dietician referral

If recurrent flare ups, seek specialist advise, surgery may be considered