Ulcerative Colitis Flashcards
Define
Chronic, relapsing-remitting inflammatory disease of the GIT
AETIOLOGY
Characterised by diffuse, continuous, superficial inflammation of the large bowel, limited to the intestinal mucosa
Usually affects the rectum with a variable length of the colon involved proximally
- Ulcerative proctitis (more common in adults)- limited to the rectum and does not extend proximally to the sigmoid colon
- Left-sided colitis- does not extend proximally beyond the splenic flexure
- Extensive colitis (MORE COMMON in children)- inflammation extends proximally beyond the splenic flexure, including pancolitis (involving entire colon)
Presentation
- Bloody diarrhoea or rectal bleeding, lasting > 6 weeks
- Faecal urgency and/or incontinence
- Nocturnal defecation
- Tenesmus
- Abdominal pain (particularly left lower quadrant)
- Pre-defecation pain, relieved on passing stool
- Non-specific signs: fatigue, malaise, anorexia, fever
- Weight loss
- Faltering growth
- Delayed puberty
- Growth failure
- Pallor, aphthous mouth ulcers
- Abdominal distension, tenderness or mass
Extra-intestinal features:
* Erythema nodosum
* Enteric arthritis
Investigation
- Abdominal examination, inspect the anorectal area if indicated
- Basic observations
- Bloods- FBC, WCC, CRP/ ESR (inflammatory markers), ferritin, U&Es, LFTs, coeliac serology
- Stool MC&S
- Faecal calprotectin (stool WBC marker in adults)
- Imaging: MRE (enterography), CT, AXR, USS
DIAGNOSIS: flexible sigmoidoscopy/ colonoscopy and biopsy (for histology), upper intestinal endoscopy
- In children, 90% have pancolitis
Histological features:
* Mucosal inflammation extending from the rectum proximally
* Crypt damage (cryptitis, architectural distortion, abscesses and crypt loss)
* Ulceration
* Small bowel imaging to check extra-colonic inflammation (Crohn’s) is not present
Management
1st line: topical -> oral aminosalicylates – if no improvement 4 weeks after starting, move to oral, then 2nd line
* Often used to maintain remission
* Can use oral azathioprine or mercaptopurine if aminosalicylates insufficient
2nd line: topical -> oral corticosteroid (i.e. if aminosalicylates not tolerated/contraindicated)
* Prednisolone
* Beclomethasone
3rd line: oral tacrolimus
4th line: biological agents (infliximab, adalimumab and golimumab)
5th line (resistant disease) -> surgery (colectomy with ileostomy or ileojejunal pouch)
Medical education / support:
* UC is associated with an increased risk of bowel cancer (Crohn’s and Colitis UK)
* Regular screening performed after 10 years of diagnosis
Severe fulminating disease – EMERGENCY
* MDT approach (medics and surgeons)
* IV corticosteroids or ciclosporin and assess likelihood of needing surgery
* Increased likelihood of needing surgery if:
* Stool frequency > 8 per day Pyrexia
* Tachycardia AXR showing colonic dilatation
* Low alb, low hb, high platelets or CRP
* Consider IV ciclosporin (if IV corticosteroids are contraindicated or ineffective)
Complications
Toxic megacolon
Bowel obstruction and perforation
Intestinal strictures, fistulas
Malnutrition, faltering growth, delayed pubertal development, growth failure
Colonic adenocarcinoma
Erythema nodosum
Enteric arthritis
Primary sclerosing cholangitis
Haemorrhage and perforation
PACES
Explain diagnosis (condition of unknown cause that leads to inflammation of bowel, which leads to symptoms)
Explain that it isn’t common but is a well-known disease (1 in 420)
Explain that there is no cure and it is a condition that tends to come and go in flare-ups every so often
Reassure that there are medications that can help reduce likelihood of flare-ups and treat flare-ups
Explain the complications (growth issues, bowel cancer)
Explain that they will be seen by a gastroenterologist
Support: Crohn’s and Colitis UK
