Ulcerative Colitis

Question 1

Definition

Answer 1

Chronic, relapsing, remitting, non-infectious inflammatory disease of the colonic mucosa, affecting the large bowel and rectum

Question 2

Inflammation in UC

Answer 2

Continuous

Usually affects rectum with variable length of the colon proximally

Never spreads proximal to ileocaecal valve (except in backwash ileitis)

Depth: limited to intestinal mucosa

Question 3

How common?

Answer 3

Most common form of IBD
10-20 per 100,000
Increasing prevalence

Question 4

Who’s affected?

Answer 4

Bimodal peak incidence: 15-30yrs and 50-70yrs

M=F

Question 5

Cause

Answer 5

Thought to be immune-mediated condition caused by environmental triggers in genetically susceptible people

Genetic association stronger in CD than UC

Smoking halves risk of UC

Question 6

Pathology

Answer 6

Affects: rectum always involved, colon, appendix, and terminal ileum (in backwash ileitis), continuous rather than patchy

Macroscopic: mucosa is reddened, inflamed and bleeds easily, ulcers may be present if severe with adjacent mucosa appearing as inflammatory polyps

Microscopic: mainly mucosal, with inflammatory cells in lamina propria, no granulomas

Inflammation: superficial

Strictures: uncommon

Crypt Abscesses: common

Goblet cells: depletion

Question 7

Classification

Answer 7

Ulcerative proctitis (30%) – inflammation limited to rectum

Proctosigmoiditis - rectum and sigmoid colon

Left sided colitis (40%) – inflammation doesn’t extend beyond splenic flexure, i.e. inflammation of rectum, sigmoid colon and descending colon

Extensive colitis (30%)– inflammation extends beyond splenic flexure, i.e. rectum, sigmoid colon, descending, transverse colon. Includes pancolitis (whole colon and rectum)

Question 8

Risk factors

Answer 8

FHx of IBD

No appendicectomy – appendicectomy before adulthood thought to be protective

NSAIDs may increase risk of flare ups

Not smoking – risk decreased in smokers i.e. smoking is protective

Stress/depression - may precipitate relapses

Question 9

Symptoms (abdominal)

Answer 9

Varies based on proximal extent of disease and inflammation severity. May present insidiously

Persistent diarrhoea – often containing blood and mucus
Faecal urgency and/or incontinence
Rectal bleeding
Nocturnal defecation
Tenesmus (persistent, painful urge to pass stool even when rectum empty)
Pre-defecation pain – relieved by passage of stool

Abdo pain, particularly in lower left quadrant

Non-specific symptoms: fatigue, malaise, anorexia, fever

Weight loss, faltering growth, delayed puberty

Question 10

How common are extraintestinal symptoms?

Answer 10

occur in 30%

Question 11

Symptoms (extraintestinal)

Answer 11

Eyes: uveitis, episcleritis, conjunctivitis

Skin: erythema nodosum, pyoderma gangrenosum, psoriasis, aphthous mouth ulcers

MSK – arthritis (large and small joints), osteoporosis, ankylosing spondylitis

Hepatobiliary - fatty liver, primary sclerosing cholangitis, autoimmune hepatitis, cirrhosis, gallstone

Renal - renal stones

Haematological: anaemia, thromboembolism

Rare: bronchiectasis, bronchitis, pancreatitis, hyperhomocysteinemia

Question 12

Signs

Answer 12

Lower abdominal pain/tenderness (left lower quadrant)
Abdominal distention/bloating
Blood on PR exam

Pallor (anaemia)
Clubbing
Ahthous mouth ulcers, erythema nodosum, pyoderma gangrenosum
Joint pain 
Signs of malnutrition/malabsorption 
Extraintestinal manifestations

Question 13

Differentials

Answer 13

Crohn's disease
Infective colitis
IBS
Coeliac disease
Diverticulitis 
Ischaemic colitis
Colorectal cancer

Question 14

Investigations

Answer 14

Blood tests:

FBC (anaemia, raised WCC)
CRP/ESR (raised)
LFTs (hypoalbuminaemia if severe)
U&Es
pANCA if supect PSC

Stool tests:

Faecal calprotectin: significantly raised (marker of intestinal inflammation, useful to distinguish between IBD and IBS)

Microscopy and culture: exclude infectious cause

Imaging:

Endoscopy gold standard for diagnosis: flexible sigmoidoscopy +/- colonoscopy (+ biopsy). Note: avoid colonoscopy in acute severe disease due to risk of bowel perforation

Plain abdo X-ray or CT

Severity classification tool for UC:

Truelove and Witt’s criteria

Question 15

Findings on endoscopy

Answer 15

Macroscopic:
continuous uniformly
inflamed mucosa
erythematous friable mucosa
abnormal vascular pattern
ulceration 
inflammatory polyps (pseudopolyps)

Microscopic:
crypt abscesses
decreased goblet cell abundance

Question 16

Management

Answer 16

2 aspects: induction of remission and maintenance of remission

MEDICAL

1ST LINE: Aminosalicylates - mesalazine (and sulfasalazine) - induction and maintenance of remission in mild-moderate UC. 1st line is topical, 2nd line is oral

Alternative to aminosalicylate: corticosteroids e.g. prednisolone - induce remission

2nd LINE: Immunosuppressants (azathioprine) - induce and maintain remission

3rd LINE: biologics such as infliximab - induce remission in severe disease

SURGICAL

Used for severe disease, uncontrollable flare ups or occurrence of severe complications e.g. toxic megacolon, bowel perforation

subtotal colectomy - resect part of colon, may have temporary ileostomy

complete proctectomy - resect entire colon and rectum, permanent ileostomy

Question 17

Complications

Answer 17

severe bleeding 
toxic megacolon 
bowel obstruction 
bowel perforation 
intestinal strictures
malnutrition 
VTE
osteoporosis
colorectal cancer