Ulcerative Colitis Flashcards by amo x

What is inflammatory bowel disease (IBD)?

It is defined as chronic, relapsing-remitting conditions in which there is inflammation of the gastrointestinal tract

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What are the two inflammatory bowel disease disorders?

Ulcerative colitis (UC)

Crohn’s disease

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What is the most common inflammatory bowel disease - ulcerative colitis or Crohn’s disease?

Ulcerative colitis

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What is ulcerative colitis?

It is a continuous inflammatory bowel disease that initially affects the rectum, however, never spreads beyond the ileocecal valve

Therefore, it is limited to the rectum and colon

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What is the underlying aetiology of ulcerative colitis?

The underlying aetiology remains unclear

However, there is evidence that the combination of an altered intestinal microbiota and compromised colonic epithelial integrity, results in the inappropriate exposure of non-sterile intestinal contents to the underlying immunological tissue – resulting in inflammation

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What are the five classifications of ulcerative colitis?

Proctitis

Proctosigmoiditis

Left Sided Colitis

Extensive Colitis

Pancolitis

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What is proctitis?

It is ulcerative colitis within the rectum only

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What is proctosigmoiditis?

It is ulcerative colitis within the rectum and sigmoid colon

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What is left sided colitis?

It is ulcerative colitis within the rectum, sigmoid colon and descending colon

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What is extensive colitis?

It is ulcerative colitis within the rectum, sigmoid colon, descending colon and transverse colon

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What is pancolitis?

It is ulcerative colitis within the rectum and entire colon

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What are the seven risk factors for ulcerative colitis?

Young Age, 15 – 30 Years Old

Middle Age, 50 – 70 Years Old

Ashkenazi Jewish Descent

IBD Family History

HLA-B27 Positive

Gastrointestinal Infection

Smoking Cessation

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What are the five clinical features of ulcerative colitis?

Bloody Diarrhoea

Bowel Urgency

Tenesmus

Left Lower Quadrant Pain

Weight Loss

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What is tenesmus?

It is defined as the sensation to pass stool, even though the bowel are empty

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What are the eight extra-intestinal manifestations of ulcerative colitis?

Primary Sclerosing Cholangitis

Colorectal Cancer

Arthritis

Osteoporosis

Erythema Nodosum

Pyoderma Gangrenosum

Uveitis

Episcleritis

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What pneumonic can be used to remember the extra-intestinal manifestations of ulcerative colitis?

A PIE SAC

Apththous ulcers

Pyoderma gangrenous

Iritis

Erythema nodosum

Sclerosing cholangitis

Arthritis

Clubbing

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What are the three most common extra-intestinal manifestation of ulcerative colitis?

Primary Sclerosing Cholangitis

Uveitis

Colorectal Cancer

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What is pyoderma gangrenosum?

It is an inflammatory disorder, in which skin ulceration occurs due to dense infiltration of neutrophils in the affected tissue

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In which region of the body does pyoderma gangrenous occur?

Lower limb

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How does pyoderma gangrenous present initially?

A small pustule, red bump or blood blister

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How does pyoderma gangrenous present in later disease?

A painful ulcer, in which the edge is purple, violaceous and undermined

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What four investigations used to diagnose ulcerative colitis?

Blood Tests

Stool Tests

Colonoscopy + Biopsy

Abdominal X-Ray (AXR)

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What are the five blood test results that indicate ulcerative colitis?

Decreased RBC Levels

Increased WCC Levels

Increased CRP Levels

Decreased Albumin Levels

Increased pANCA Levels

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What two stool tests are used to diagnose ulcerative colitis?

Faecal Calprotectin

Stool Culture

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What is faecal calprotectin?

It is an inflammatory marker, which is released during colitis

What faecal calprotectin result indicates ulcerative colitis?

There are elevated levels of this inflammatory marker present in stool cultures – usually > 200ug/g

How is faecal calprotecin used to investigate ulcerative colitis?

This stool test is useful for distinguishing between inflammatory bowel syndrome and inflammatory bowel disease

How are stool cultures used to investigate ulcerative colitis?

They are used to exclude gastrointestinal infections

What three gastrointestinal infections present similarly to ulcerative colitis, and are therefore important to exclude?

Salmonella E.coli Campylobacter

What is the gold standard investigation used to diagnose ulcerative colitis?

Colonoscopy, with biopsy

What are the five macroscopic features of ulcerative colitis on colonoscopy?

Continuous Uniformly Inflamed Mucosa Erythematous Mucosa Inflammatory Cells Infiltrate Lamina Propria Layer No Inflammation Beyond Submucosa Widespread Ulceration With Pseudopolyps

What are the two microscopic features of ulcerative colitis on colonoscopy?

Crypt Abscesses Decreased Goblet Cell Abundance

In which circumstance is colonoscopy contraindicated in ulcerative colitis? Why? What is an alternative investigation?

In acute severe disease relapses This is due to the increased risk of bowel perforation Instead, a flexible sigmoidoscopy is recommended

What are the four features of ulcerative colitis on abdominal x-ray?

Haustration Loss Pseudopolyps Toxic Megacolon Lead Pipe Appearance

What investigation is most important to conduct during ulcerative colitis relapse? Why?

Abdominal X-Ray This allows identification of toxic megacolon

What scoring system is used to classify the severity of ulcerative colitis?

‘Truelove & Witts’ criteria

What is mild ulcerative colitis?

It is defined as the passage of < 4 stools per day with a small amount of blood present

What is moderate ulcerative colitis?

It is defined as the passage of 4 – 6 stools per day with varying amounts of blood present

What is severe ulcerative colitis?

It is defined as the passage of > 6 stools per day with features of systemic upset... - Fever > 37.8C - Heart Rate > 90 - Haemoglobin < 105 - ESR > 30

What is the first line management option for remission induction, in mild/moderate proctitis?

Topical aminosalicylates (5-ASA)

Name an aminosalicylates (5-ASA) used to manage ulcerative colitis

Mesalazine

What is the second line management option for remission induction, in mild/moderate proctitis?

ADD Oral aminosalicylates (5-ASA)

When is second line management option for remission induction, in mild/moderate proctitis recommended?

When remission is not obtained within four weeks

What is the third line management option for remission induction, in mild/moderate proctitis?

Oral corticosteroids

Name an oral corticosteroid used to manage ulcerative colitis

Prednisolone

What is the first line management option for remission induction, in mild/moderare proctosigmoiditis and left sided ulcerative colitis?

Topical Aminosalicylate

What is the second line management option for remission induction, in mild/moderare proctosigmoiditis and left sided ulcerative colitis?

ADD a high dose oral aminosalicylate OR Switch to a high dose-oral aminosalicylate and a topical corticosteroid

When is the second line management option for remission induction, in mild/moderare proctosigmoiditis and left sided ulcerative colitis recommended?

When remission is not obtained within four weeks

What is the third line management option for remission induction, in mild/moderare proctosigmoiditis and left sided ulcerative colitis?

Stop topical treatements AND Offer an oral aminosalicylate and an oral corticosteroid

What is the first line management option for for remission induction, in mild/moderare extensive ulcerative colitis?

Topical aminosalicylate and a high dose oral aminosalicylate

What is the second line management option for remission induction, in mild/moderare extensive ulcerative colitis?

Stop topical treatments AND Offer a high dose oral aminosalicylate and an oral corticosteroid

What is the first line management option for remission induction, in severe ulcerative colitis?

IV corticosteroids

Name an IV corticosteroid used to manage ulcerative colitis

Hydrocortisone

What is the second line management option for remission induction, in severe ulcerative colitis?

IV DMARDs

Name an IV DMARD used to manage ulcerative colitis

Ciclosporin

When is second line management recommended in for remission induction recommended in severe ulcerative colitis?

If there is no improvement after 72 hours

What are the three first line management options for remission maintenance in mild/moderate protcitis and proctosigmoiditis?

Topical Aminosalicylates (5-ASA) Or An oral aminosalicylate and a topical ainosalicylate OR An oral aminosalicyte

What is the first line management options for remission maintenance in mild/moderate left sided and extensive ulcerative colitis?

A low maintenance dose of an oral aminosalicylate

What is the management option for remission maintenance following a severe relapse or more than two exacerbations of ulcerative colitis in the past year?

Oral Thiopurine

Name two thiopurines used to manage ulcerative colitis

Azathioprine Mercaptopurine

When are thiopurines recommended in ulcerative colitis remission maintenance?

Severe relapses OR > 2 relapses per year

What is the third line management option for remission maintenance in ulcerative colitis?

Biologics

Name three biologics used to manage ulcerative colitis

Infliximab Ustekinumab Vedolizumab

What is the mechanism of action of infliximab?

Anti-TNFa

What is the mechanism of action of ustekinumab?

Anti-IL-12/23

What is the mechanism of action of vedolizumab?

Anti 14b7

When are biologics recommended in ulcerative colitis remission maintenance?

Severe relapses OR > 2 relapses per year

What is the fourth line management option for remission maintenance in ulcerative colitis?

Surgical management

What are the three surgeries used to manage ulcerative colitis?

Subtotal Colectomy Complete Proctocolectomy Panproctocolectomy & Ileoanal Pouch

When is subtotal colectomy used to manage ulcerative colitis?

It is recommended to manage individuals with a sudden and severe flare, in which pharmacolgoical management is deemed unsuccessful

What is subtotal colectomy?

It involves resection of most of the colon, with preservation of the sigmoid colon

Can bowel function be restored following a subtotal colectomy?

Yes

How do we restore bowel function in individuals who undergo subtotal colectomy?

These patients undergo an ileo-anal anastomosis (J-Pouch), in which the ileum is folded back on itself and fashioned into a larger pouch that functions like a rectum The J-Pouch is then attached to the anus to restore normal bowel function

What is a complete protocolectomy?

It involves resection of the entire colon and rectum

Can bowel function be restored following a complete protocolectomy?

No These individuals don’t undergo further anastomotic surgery and thus have a permanent stoma

What are the two forms of stomas?

Ileostomy Colostomy

What stoma is usually formed following complete protocolectomy?

Ileostomy

What is the location of ileostomies? What is the appearance? Describe the output appearance

Right iliac fossa Spouted Liquid

What is the location of colostomies? What is the appearance? Describe the output appearance

Varied - usually on left side of abdomen Flushed Solid

When is panproctocolectomy and ileoanal pouch used to manage ulcerative coliti?

It is used in cases where pharmacological mamagement is unsuccessful and individuals wish to avoid a permanent stoma However, it is only offerred in the elective setting

What is panprotocolectomy and ileoanal pouch?

It involves resection of the entire colon and rectum, with formation of a temporary loop ileostomy

Can bowel function be restored following a restorative protocolectomy?

Yes

How do we restore bowel function in individuals who undergo restorative protocolectomy?

The loop ileostomy is later reversed with further surgery to create an ileo-anal anastomosis (J-Pouch)

What are the five complications of ulcerative colitis?

Bowel Perforation Toxic Megacolon Malnutrition Venous Thromboembolism Colorectal Cancer

What are the four clinical features associated with toxic megacolon?

Fever Severe Abdominal Pain Tachycardia Hypertension

What four blood test results indicate toxic megacolon?

Decreased Hb Levels Increased Plt Levels Increased WBC Levels Increased CRP Levels

What two features indicate toxic megacolon on abdominal x-ray?

Dilated transverse colon > 9cm Thumb printing in descending colon wall

What pneumonic can be used to remember the key features of ulcerative colitis?

U-C CLOSEUP Continuous inflammation Limited to rectum and colon Only superficial mucosa affected Smoking protective Excrete blood and mucus Use aminoglycosides Primary sclerosing cholangitis