Ulcerative Colitis

Question 1

A 38 year old woman presents with a two day history of profuse bloody diarrhoea with fever. She was diagnosed as having ulcerative colitis 10 years ago and has been treated with salazopyrine and corticosteroids. She has not had any symptoms for the past three years and ceased all treatment six months ago. How would you assess and manage her?

Answer 1

Impression
Flare of IBD given recent cessation of maintenance medications. This is a medical emergency demanding prompt treatment with supportive measures along with

Ddx to consider;

• Infective: Shigella, campylobacter, salmonella
• IBD: Crohns
• meds ABx +/- pseudomembranous colitis
• Neoplastics: CRC,
• Vascular: angiodysplasia, diverticular bleed
• Perianal disease

Key complications of UC:
- toxic megacolon +/- perforation

Goals

• Targeted Hx/Ex/Ix to determine likely aetiology
• Consult with gastro, likely restart of UC pharmacotherapy first with induction therapy then long-term ongoing treatment with maintenance therapies.

Question 2

UC - History

Answer 2

History

• Sx: severity >6 bloody stools, associated sx (pain, cramps, location, temperature, weightless/anorexia, N/V?)
• onset, duration, preceding features, or preceding illness?/diarrhoeal illness
• consequences: fatigue, lethargy, pallor, pica, etc
• Other: sick contacts, recent overseas travel, ABx use, known diverticular disesae
• PMHx: known extent of UC disease, details of treatment, any surgical treatments (?resection) ?pregnant,
• SNAP

Question 3

UC - Examination

Answer 3

Examination
- General appearance + vitals (HD stability)
- Abdo exam: focal tenderness, distension, bowel sounds
- PR examination: blood, mucous, rectal masses, fissures/haemorrhoids
- Extra-intestinal signs of IBD:
o iritis
o aphthous ulcers
o derm: pyoderma gangrenosum, erythroderma nodosum
o arthritis
- Hydration status assessment

Question 4

UC - Investigations

Answer 4

Investigations

• Bedside: UA, stool MCS + OCP
• bloods: FBC, UEC, LFT, CRP/ESR, cultures given fevers, ASCA/P-ANCA
• Imaging: AXR for ?toxic megaocolon, CT abdo

Question 5

UC - Management

Answer 5

Management

• Call for gastro consult and input early
• get senior support early in presentation

Supportive

• analgesia
• antipyretics
• fluids + electrolyte replacement
• VTE prophylaxis
• stool charting, daily weights

Definitive:
Induction therapy
- Sulphasalazine IV
- Corticosteroids IV
+/- other non-steroidal immunomodulators (azathioprine, mycophenolate, leflunomide, etc)
+/- empirical ABx: ciprofloxacin and metronidazole

May need to consider role for colectomy in acute setting if severe and non-responsive despite IV corticosteroids

Maintenance
- sulphasalazine +/- other non-steroidal immunomodulators +/- biologics

In fulminant colitis, give broad spectrum ABx, may require decompression or colectomy.