Ulcerative Colitis

Question 1

Ulcerative colitis

Answer 1

• chronic inflammatory disease that involves whole or part of colon
• confined to mucosa
• always involve rectum extending to involve distal or total colon

Question 2

Aetiology

Answer 2

• smoking (protective factor)
• immunological
• dietary
• genetic factor
• 25 and 30 years old
• malignant change in colon over time

Question 3

Pathology

Answer 3

• oedema of mucosa with contact bleeding and petechial haemorrhage–> ulceration (shallow and irregular)–> pseudopolyps–> wall of colon is oedematous, fibrotic and loss of normal haustration
• changes are confluent
• inflamed colon does not adherent to neighbouring intra-abdominal viscera

Microscopically

• crypt abscesses–> break down into ulcer (base lined with granulation tissue)
• wall of colon is infiltrated with polymorphs and round cells
• oedema and submucosal fibrosis

Question 4

Clinical feature

Answer 4

• bloody diarrhoea and urgency
• rectal bleeding
• tenesmus
• mucous discharge
• cramp-like abdominal pain
• fever
• weight loss

Question 5

Physical examination

Answer 5

• pallor
• malnutrition
• abdominal tenderness
• abdominal distension
• erythema nodosum
• pyoderma gangrenosum
• arthritis
• uveitis
• Jaundice (sclerosing cholangitis)

Rectal examination

• blood on glove of examining finger
• rectal mucosa feel oedematous

Question 6

Investigation

Answer 6

• FBC: iron deficiency anaemia, raised WBC and platelet count
• ESR and CRP: raised
• U&E : dehydration and electrolyte imbalance
• LFT: hypoalbuminaemia (complication of sclerosing cholangitis)
• stool culture: exclude infective colitis ( Campylobacter, Clostridium difficile)

Question 7

Imaging studies

Answer 7

• AXR: severe attacks to exclude colonic dilatation, development of toxic megacolon
• CT: assess disease extent or complication
• barium enema: loss of haustrations, mucosal distortion, colonic shortening, stricture due to carcinoma (lead pipe appearance)

Question 8

Specific test

Answer 8

• colonoscopy and biopsy : gold standard
  1. determine the extent of inflammation
  2. Distinguish between UC and Crohn’s disease
  3. Monitor response to treatment
  4. Assess longstanding cases for malignant change
• sigmoidoscopy : red, inflamed mucosa, contact bleeding, pseudopolyps

Question 9

Complication

Answer 9

• toxic dilatation
• haemorrhage
• stricture
• perforation
• carcinoma
• perianal disease (anal fissure)

Extra-intestinal

• seronegative arthritis (sacroileitis, ankylosing spondylitis)
• sclerosing cholangitis
• chronic active hepatitis
• uveitis
• amyloid

Question 10

Medical Treatment

Answer 10

Medical
- IV fluid, blood transfusion, parenteral nutrition and parenteral steroid (5 days)

• corticosteroid : treatment of flareups, anti-inflammatory action
• 5-aminosalicyclic acid (5-ASA)- sulfasalazine: inhibitor of cyclo-oxygenase enzyme, protect aspirin-related drug from degradation before reaching colon, long term as maintenance therapy
• immunosuppressive drugs (azathioprine and cyclosporine) : maintain remission and as steroid sparing agents
• monoclonal antibodies (infliximab and adalimumab) : against anti-tumour necrosis factor alpha

Question 11

Surgical

Answer 11

Indication

• failure of medical therapy/ steroid dependence
• growth retardation in young
• Extra-intestinal disease
• malignant change

Subtotal colectomy with end ileostomy

Completion proctectomy (+- ileoanal pouch

Question 12

Screening

Answer 12

• if pancolitis >10 years: screen to detect clinically silent dysplasia–> increased risk for colorectal cancer