Ulcerative Colitis

Question 1

What is the pattern of disease in UC?

Answer 1

Relapsing-remitting

Question 2

UC most commonly presents between the ages of ___________ and __________, although diagnosis can be made at any age

Answer 2

15

25

Question 3

What is the pattern of inflammation in UC?

Answer 3

continuous, extending from the rectum upwards to a varying degree

Question 4

Inflammation of the rectum is referred to as ______________, and inflammation of the rectum and sigmoid colon as _____________

Answer 4

proctitis

proctosigmoiditis

Question 5

Left-sided colitis refers to disease involving the colon distal to the _______________. Extensive colitis affects the colon proximal to the ____________, and includes pan-colitis, where the ____________ colon is involved

Answer 5

splenic flexure

splenic flexure

whole

Question 6

______________ colitis refers to disease involving the colon distal to the splenic flexure. ___________ affects the colon proximal to the splenic flexure, and includes _____________, where the whole colon is involved

Answer 6

Left-sided

Extensive colitis

pan-colitis

Question 7

What are the common symptoms of active UC or relapse? (3)

Answer 7

1. Bloody diarrhea
2. Urgent need to defecate
3. Abdominal pain

Question 8

What are the complications of UC? (4)

Answer 8

1. increased risk of CRC
2. Secondary osteoporosis
3. VTE
4. Toxic megacolon

Question 9

Management of ulcerative colitis is dependent on factors such as _______________, ______________, and _______________

Answer 9

clinical severity

extent of disease

patient preference

• Clinical and laboratory investigations are used to determine the extent and severity of disease and to guide treatment

Question 10

Severity is classified as mild, moderate or severe by using the _________________ to assess bowel movements, heart rate, erythrocyte sedimentation rate and the presence of pyrexia, melaena or anaemia

Answer 10

Truelove and Witts’ Severity Index

Question 11

Severity is classified as mild, moderate or severe by using the Truelove and Witts’ Severity Index to assess: … (6)

Answer 11

1. bowel movements
2. heart rate
3. erythrocyte sedimentation rate
4. presence of pyrexia
5. melaena
6. anaemia

Question 12

The extent of disease should be considered when choosing the route of administration for aminosalicylates and corticosteroids; whether oral treatment, topical treatment or both are to be used. If the inflammation is _____________, a rectal preparation is adequate but if the inflammation is _____________, systemic medication is required

Answer 12

distal

extended

• Either suppositories or enemas can be offered, taking into account the patient’s preferences

Question 13

The extent of disease should be considered when choosing the route of administration for aminosalicylates and corticosteroids; whether oral treatment, topical treatment or both are to be used. If the inflammation is distal, a(n) ______________ preparation is adequate but if the inflammation is extended, ____________ medication is required

Answer 13

rectal

systemic

• Either suppositories or enemas can be offered, taking into account the patient’s preferences

Question 14

Rectal __________ preparations and __________ can be used when patients have difficulty retaining liquid enemas

Answer 14

foam

suppositories

Question 15

Diarrhoea associated with ulcerative colitis is sometimes treated with anti-diarrhoeal drugs (such as ________________ or ______________) on the advice of a specialist; however their use is contraindicated in acute ulcerative colitis as they can increase the risk of toxic megacolon

Answer 15

loperamide hydrochloride

codeine phosphate

Question 16

Diarrhoea associated with ulcerative colitis is sometimes treated with anti-diarrhoeal drugs (such as loperamide hydrochloride or codeine phosphate) on the advice of a specialist; however their use is contraindicated in acute ulcerative colitis as they can increase the risk of ________________

Answer 16

toxic megacolon

Question 17

Diarrhoea associated with ulcerative colitis is sometimes treated with anti-diarrhoeal drugs (such as loperamide hydrochloride or codeine phosphate) on the advice of a specialist; however their use is contraindicated in __________________ as they can increase the risk of toxic megacolon

Answer 17

acute ulcerative colitis

Question 18

Are anti-diarrheal drugs safe to use in UC?

Answer 18

Yes, UNLESS acute UC in which case there is a risk of toxic megacolon

Question 19

A topical aminosalicylate is recommended as first-line treatment for patients with a mild-to-moderate initial presentation or inflammatory exacerbation of ____________

Answer 19

proctitis

Question 20

A topical _______________ is recommended as first-line treatment for patients with a mild-to-moderate initial presentation or inflammatory exacerbation of proctitis

Answer 20

aminosalicylate

Question 21

If remission of acute proctitis is not achieved within 4 weeks of treatment with topical aminosalicylates, adding a(n) _______________ should be considered. If response remains inadequate, consider addition of a topical or an oral ________________ for 4 to 8 weeks

Answer 21

oral aminosalicylate

corticosteroid

Question 22

Monotherapy with _________________ can be considered for patients who prefer not to use enemas or suppositories, although this may not be as effective

Answer 22

an oral aminosalicylate

• If remission is not achieved within 4 weeks, adding a topical or an oral corticosteroid for 4 to 8 weeks should be considered

Question 23

A topical or an oral corticosteroid for ____________ weeks should be considered for patients with UC in whom aminosalicylates are unsuitable

Answer 23

4 to 8

Question 24

A(n) _________________ is recommended as first-line treatment for patients with a mild-to-moderate initial presentation or inflammatory exacerbation of proctosigmoiditis or left-sided ulcerative colitis

Answer 24

topical aminosalicylate

Question 25

A topical aminosalicylate is recommended as first-line treatment for patients with a mild-to-moderate initial presentation or inflammatory exacerbation of proctosigmoiditis or left-sided ulcerative colitis. If remission is not achieved within 4 weeks, consider adding a(n) _______________, or switching to a(n) _______________ and 4 to 8 weeks of _______________. If response remains inadequate, stop topical treatment and offer an oral aminosalicylate and 4 to 8 weeks of an oral corticosteroid

Answer 25

high-dose oral aminosalicylate

high-dose oral aminosalicylate

a topical corticosteroid

Question 26

A topical aminosalicylate is recommended as first-line treatment for patients with a mild-to-moderate initial presentation or inflammatory exacerbation of proctosigmoiditis or left-sided ulcerative colitis. If remission is not achieved within 4 weeks, consider adding a high-dose oral aminosalicylate, or switching to a high-dose oral aminosalicylate and 4 to 8 weeks of a topical corticosteroid. If response remains inadequate, stop topical treatment and offer _____________ and 4 to 8 weeks of _____________

Answer 26

an oral aminosalicylate

an oral corticosteroid

(1. Topical ASA
2. Topical ASA + oral ASA or oral ASA + topical CS)
3. Oral ASA + oral CS)

Question 27

What is the first line treatment of mild-moderate extensive UC?

Answer 27

Topical ASA + high dose oral ASA

If remission not achieved within 4 weeks, stop topical ASA and offer high dose oral ASA + 4-8 wks of oral CS

Question 28

If remission of mild-moderate extensive UC is not achieved within 4 weeks of starting topical ASA and high dose oral ASA, stop topical aminosalicylate treatment and offer _________________ and _______________.

Answer 28

a high-dose oral aminosalicylate

4 to 8 weeks of an oral corticosteroid

Question 29

How is acute severe UC treated?

Answer 29

Immediate hospital admission;

*Acute severe ulcerative colitis of any extent can be life-threatening and is regarded as a medical emergency

Question 30

____________________ should be given to induce remission in patients with acute severe ulcerative colitis (at first presentation or an exacerbation) while assessing the need for surgery

Answer 30

Intravenous corticosteroids (such as hydrocortisone or methylprednisolone)

Question 31

If intravenous corticosteroids are contra-indicated, declined or cannot be tolerated, then ________________ or ______________ should be considered

Answer 31

intravenous ciclosporin [unlicensed indication]

surgery

Question 32

A combination of ______________ with _______________, or ______________ is second line therapy for patients with acute severe UC who have little or no improvement within 72 hours of starting intravenous corticosteroids or whose symptoms worsen despite treatment

Answer 32

intravenous ciclosporin

intravenous corticosteroids

surgery

Question 33

______________ can be used to treat acute exacerbations of severely active ulcerative colitis if ciclosporin is contra-indicated or clinically inappropriate

Answer 33

Infliximab

Question 34

In patients who experience an initial response to steroids followed by deterioration, stool cultures should be taken to exclude the presence of pathogens; ______________ activation should be considered

Answer 34

cytomegalovirus

Question 35

To reduce the chances of relapse occurring, maintenance therapy with ______________ is recommended in most patients with UC.

Answer 35

an aminosalicylate

• Corticosteroids are not suitable for maintenance treatment because of their side-effects

Question 36

Are corticosteroids suitable for maintaining relapse in patients with UC?

Answer 36

No due to their side-effects

Question 37

Maintaining remission in UC:
After a mild-to-moderate inflammatory exacerbation of proctitis or proctosigmoiditis,
______________ can be started alone or in combination with an oral aminosalicylate, administered daily or as part of an intermittent regimen (such as twice to three times weekly or the first seven days of each month)

Answer 37

a rectal aminosalicylate

• An oral aminosalicylate can be used alone in patients who prefer not to use enemas or suppositories, although this may not be as effective

Question 38

A _______________ is given to maintain remission in patients after a mild-to-moderate inflammatory exacerbation of left-sided or extensive ulcerative colitis

Answer 38

low-dose of oral aminosalicylate

Question 39

When used to maintain remission, single daily doses of oral aminosalicylates can be more effective than multiple daily dosing, but may result in _______________

Answer 39

more side-effects

Question 40

Oral _________________ can be considered to maintain remission in UC, if there has been two or more inflammatory exacerbations in a 12-month period that required treatment with systemic corticosteroids, or if remission is not maintained by aminosalicylates, or following a single acute severe episode

Answer 40

azathioprine or mercaptopurine [unlicensed indications]

*JAK inhibitors are also used in the treatment of UC

Question 41

Is MTX an effective drug in treating acute UC or maintaining remission?

Answer 41

No evidence to support its use in either

Question 42

___________ may be necessary as emergency treatment for severe ulcerative colitis that does not respond to drug treatment

Answer 42

Surgery

Question 43

Patients can also choose to have _______________ for unresponsive or frequently relapsing UC that is affecting their quality of life

Answer 43

elective surgery

Question 44

Aminosalicylates (ASA) include: (4)

Answer 44

1. Mesalazine
2. Sulfasalazine
3. Balsalazide
4. Olsalazine

(All contain 5-aminosalicylic acid)