Ulcerative Colitis Flashcards
Peak age incidence for UC
15-40yrs old
Incidence in people >60 is increasing though
Pathophysiology of UC
- Environmental exposures
- Genetic predisposition
- Dysregulated immune response
- Dysbiosis - altered gut microbiota
Histological changes UC
- Non-granulomatous inflammation - submucosa and mucosa
- Crypt abscesses
- Goblet cell hypoplasia
- Can get pseudopolyps from repeated cycles of ulceration and healing - raised areas
Smoking UC
Protective role - unlike in Crohns
Symptoms of UC
- Most common - proctitis
- Inflammation confined to rectum
- Bloody diarrhoea
- Others inc mucus discharge PR, increased stool freq and urgency, tenesmus
If widespread colonic involvement, what are some additional symptoms?
- Dehydration
- Systemic symptoms eg malaise, anorexia, low grade pyrexia
Disease grading for UC
- Truelove and Witt criteria
- Based on bowel movements, blood in stool, pyrexia, pulse, anaemia, ESR
Extra-intestinal manifestations of UC
SAME AS CROHNS - recall list of MSK, skin, eyes, hepatobiliary
But no renal
Investigations UC - bloods and bedside
- Same as Crohns
- Bloods- FBC, LFT (albumin), CRP
- Faecal calprotectin
- Stool MC&S
Imaging for UC
- Colonoscopy with biopsy = most sensitive and specific tool for diagnosis
- Acute flare - urgent CT - check for obstruction, toxic megacolon or perforation
Endoscopic findings of mild and then moderate/severe UC
- Clear demarcation where inflammation ends
- Erythema
- Vascular congestion
If more severe:
* Loss of vascular patterns
* Mucosal friability
* Ulcers
* Pseudopolyps
Scoring system for extent and severity of UC
- Extent - Montreal score
- Severity - Mayo score
AXR signs of acute flare UC
- Mural thickening
- Thumb printing sign (wall oedema)
- Lead pipe colon if severe, chronic case - muscularis mucosae hypertrophy
General management UC
- Same as Crohns
- Refer to gastro
- IBD MDT input
- IBD nurse specialists
- Consider enteral nutrition and low fibre diets
Surveillance for UC
- Same as Crohns
- Endoscopic surveillance for colorectal cancer
- If had disease more than 10 years and more than 1 segment of bowel affected
Medical management - mild to moderate UC
- Mesalazine for inducing remission and maintanance
- Can be suppository for proctitis or orally if left sided/extensive colitis
- If not responding to mesalazine, try corticosteroids
Moderate to severe disease UC management
- Corticosteroids
- If improve, biologics eg anti TNF (infliximab) or vedolizumab or thiopurines (azathiopruine) can be used for maintenance
Management of acute flare of UC
- Admission usually
- IV corticosteroids
- If these fail - ciclosporin or inflximab therapy - surgery if not improved after 4-7 days
- Fluids
- Prophylactic heparin + antiembolic stockings - prothrombotic state
Surgical management UC indications
- Emergency - toxic megacolon, colonic perforation uncontrolled bleeding
- Elective - medically refractory disease, medication intolerance, colorectal cancer (or endoscopically irresectable dysplasia)
Emergency surgery often done for UC
- Segmental or subtotal colectomy with stoma formation
- Subtotal is whole colon gone but leave rectum and anus
- Segmental is portion of colon removed
Elective operation choice often
- Proctocolectomy and ileal pouch anal anastomosis - esp if keen to avoid stoma
- Often done staged approach - 3 stages, allows recovery between procedures and reduces patient morbidity
- Other option is proctocolectomy with end ileostomy
3 stages of proctocolectomy and ileal-pouch anal anastomosis
- Subtotal colectomy with end ileostomy
- Completion proctectomy and ileal-pouch anal anastomosis formation with temporary loop ileostomy
- Ileostomy reversal
Complications of UC
- Toxic megacolon
- Colorectal adenocarcinoma
- Pouchitis - inflammation if ileal pouch if undergone an IPAA
Presentation and management toxic megacolon
- Abdominal pain, distension, pyrexia and systemic upset
- Decompression of bowel - high risk of perforation, failure to respond to medical therapy = indication for surgery (NBM and NG tube)
Presentation and management pouchitis
- Bloody diarrhoea and abdominal pain
- Metronidazole and ciprofloxacin
