Ulcerative Colitis Flashcards
What is inflammatory bowel disease (IBD)?
It is defined as chronic, relapsing-remitting conditions in which there is inflammation of the gastrointestinal tract
What are the two inflammatory bowel disease disorders?
Ulcerative colitis (UC)
Crohn’s disease
What is the most common inflammatory bowel disease - ulcerative colitis or Crohn’s disease?
Ulcerative colitis
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
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
What are the five classifications of ulcerative colitis?
Proctitis
Proctosigmoiditis
Left Sided Colitis
Extensive Colitis
Pancolitis
What is proctitis?
It is ulcerative colitis within the rectum only
What is proctosigmoiditis?
It is ulcerative colitis within the rectum and sigmoid colon
What is left sided colitis?
It is ulcerative colitis within the rectum, sigmoid colon and descending colon
What is extensive colitis?
It is ulcerative colitis within the rectum, sigmoid colon, descending colon and transverse colon
What is pancolitis?
It is ulcerative colitis within the rectum and entire colon
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
What are the five clinical features of ulcerative colitis?
Bloody Diarrhoea
Bowel Urgency
Tenesmus
Left Lower Quadrant Pain
Weight Loss
What is tenesmus?
It is defined as the sensation to pass stool, even though the bowel are empty
What are the eight extra-intestinal manifestations of ulcerative colitis?
Primary Sclerosing Cholangitis
Colorectal Cancer
Arthritis
Osteoporosis
Erythema Nodosum
Pyoderma Gangrenosum
Uveitis
Episcleritis
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
What are the three most common extra-intestinal manifestation of ulcerative colitis?
Primary Sclerosing Cholangitis
Uveitis
Colorectal Cancer
What is pyoderma gangrenosum?
It is an inflammatory disorder, in which skin ulceration occurs due to dense infiltration of neutrophils in the affected tissue
In which region of the body does pyoderma gangrenous occur?
Lower limb
How does pyoderma gangrenous present initially?
A small pustule, red bump or blood blister
How does pyoderma gangrenous present in later disease?
A painful ulcer, in which the edge is purple, violaceous and undermined
What four investigations used to diagnose ulcerative colitis?
Blood Tests
Stool Tests
Colonoscopy + Biopsy
Abdominal X-Ray (AXR)
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
What two stool tests are used to diagnose ulcerative colitis?
Faecal Calprotectin
Stool Culture
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
