Ulcerative Colitis

Question 1

What is ulcerative colitis?

Answer 1

Ulcerative colitis is an inflammatory bowel disease (IBD) that causes inflammation and ulcers in your digestive tract. Ulcerative colitis affects the innermost lining of your large intestine and rectum. Symptoms usually develop over time, rather than suddenly.

Question 2

What part of the GI is inflamed in UC?

Answer 2

Ulcerative colitis can affect the rectum alone (proctitis), can extend proximally to involve the sigmoid and descending colon (left-sided colitis), or may involve the whole colon (extensive colitis)

Question 3

What is proctitis?

Answer 3

Ulcerative colitis of the rectum

Question 4

What is left-sides colitis?

Answer 4

Ulcerative colitis of the rectum, sigmoid and descending colon

Question 5

What is the age of onset for UC?

Answer 5

15-35 and 55-70

Question 6

How does smoking relate to ulcerative colitis?

Answer 6

Protective factor

Question 7

What causes ulcerative colitis?

Answer 7

The cause of UC is unknown. Theories involve immune system dysfunction, genetics, changes in the normal gut bacteria, and environmental factors.

Question 8

What are microscopic changes seen in ulcerative colitis?

Answer 8

1. The mucosa shows a chronic inflammatory cell infiltrate in the lamina propria.
2. Crypt abscesses
3. Goblet cell depletion
4. Very rare that there are goblet cells

Question 9

What are macroscopic chances seen in ulcerative colitis?

Answer 9

1. Mucosa looks reddened and inflamed, it bleeds easily. Inflammation is continuous
2. In severe disease, there is extensive ulceration with the adjacent mucosa appearing as inflammatory (pseudo) polyps

Question 10

What are the symptoms of ulcerative colitis?

Answer 10

The major symptom in UC is diarrhoea with blood and mucus, sometimes accompanied by lower abdominal discomfort

General features:

1. Malaise
2. fatigue
3. Anorexia
4. Aphthous ulceration in the mouth
5. Tenesmus

Question 11

What are symptoms specific to proctitis?

Answer 11

Proctitis is characterized by the frequent passage of blood and mucus, urgency and tenesmus. There are normally few constitutional symptoms and the stool when passed, may be solid. Patients are nevertheless greatly inconvenienced by the frequency of defecation.

Question 12

What is the course of ulcerative colitis?

Answer 12

The disease can be mild, moderate and severe and often runs a course of remissions and exacerbations. Of the patients, 10% have persistent chronic symptoms, while some patients may have only a single attack.

Question 13

How is ulcerative colitis diagnosed?

Answer 13

Presence of chronic diarrhoea for more than 4 weeks and presence of acute inflammation on endoscopy and chronic changes on biopsy

Question 14

What would a colonoscopy in ulcerative colitis show?

Answer 14

Endoscopic findings in ulcerative colitis include erythema (redness of the mucosa), friability of the mucosa, superficial ulceration, and loss of the vascular appearance of the colon

Histologic findings in ulcerative colitis includes distortion of crypt architecture, crypt abscesses, and inflammatory cells in the mucosa. Limited inflammation only in mucosa

Question 15

What are the aims of drug treatment in ulcerative colitis?

Answer 15

1. Treat acute attack

2. Prevent relapse

Question 16

How is ulcerative colitis managed pharmacologically?

Answer 16

The therapeutic treatment for UC includes 5-aminosalicylic acid (5-ASA)

The aminosalicylates have been shown to be effective in inducing remission in mild to moderately active disease and maintaining remission in all forms of disease

Corticisteroids are used in more severe cases

Question 17

What is the mechanism of action of 5-aminosalicylic acid (5-ASA)?

Answer 17

5-aminosalicylic acid is now believed to act by activating a class of nuclear receptors involved in the control of inflammation, cell proliferation, apoptosis and metabolic function, the gamma form of peroxisome proliferator-activated receptors.

Question 18

Can ulcerative colitis be managed surgically?

Answer 18

While the treatment of UC remains primarily medical, surgery continues to have a central role because it may be life-saving, is curative and eliminates the long-term risk of cancer

The main indication for surgery is for a severe attack which fails to respond to medical therapy

Question 19

What are poor prognostic factors for ulcerative colitis?

Answer 19

Age < 40 on onset
Extensive colitis
Severe colitis on endoscopy
Elevated CRP and low serum albumin

Question 20

What are the oncological risks of ulcerative colitis?

Answer 20

The risk of colorectal cancer is significantly increased in people with ulcerative colitis after ten years if involvement is beyond the splenic flexure.

Question 21

What are the mortality risks of ulcerative colitis?

Answer 21

People with ulcerative colitis are at similar or perhaps slightly increased overall risk of death compared with the background population

Question 22

How does ulcerative colitis differ from crohns?

Answer 22

UC: continuous and uniform inflammation of large bowel
CD: patchy inflammation anywhere in GI (skip lesions)

UC: stool urgency, fatigue, increased bowel movements, mucus in stool
CD: abdominal pain, diarrhoea, weight loss

UC: submucosal and mucosal diarrhoea
CD: transmural

UC: depleted goblet cells, lot of crypt abscesses, potential pseudopolyps
CD: granulomas, goblet cells

Question 23

What is another name for 5-ASA given in Ulcerative Colitis?

Answer 23

Mesalazine

Question 24

What dose of mesalazine would you give in ulcerative colitis?

Answer 24

Depends on anatomy

Mild rectosigmoid: 1 gram 4-6 weeks (rectal)
Mild descending colon: 2 grams 4-6 weeks (rectal)

Mild-moderate: 2.4 grams (oral)

Maintenance of remission: 1.2-2.4 grams daily (oral)