Ulcerative colitis Flashcards
What is ulcerative colitis (UC)?
Ulcerative colitis (UC) is a chronic inflammatory condition characterized by a relapsing and remitting course and continuous mucosal inflammation of the colon without granulomas on biopsy.
What areas of the body does UC affect?
UC affects the rectum and a variable extent of the colon.
At what age do patients usually present with UC?
Patients usually present with UC in late adolescence or early adulthood, but it can occur at any age.
Does UC affect both sexes equally?
Yes, UC affects both sexes equally.
How is distribution of disease in UC described as?
The distribution of disease is described by the maximal macroscopic extent of inflammation noted at colonoscopy.
The Montreal classification is commonly used to define the distribution of disease (Fig 1)
How is disease activity in UC determined?
How is UC diagnosed?
Diagnose UC through a combination of:
Medical history, plus
Clinical assessment, plus
Endoscopic (Fig 1) and histological findings
DDX for UC
Differential diagnoses
Crohn’s colitis
Infective aetiologies
Diverticulitis
Colorectal malignancy
Microscopic colitis
Ischaemic colitis
NSAID-induced colitis
Which medication can potentially exacerbate UC?
NSAIDs
How can differentiate between diarrhea caused by infectious etiologies and UC?
The occurrence of loose stools for more than 6 weeks differentiates UC from the majority of infectious aetiologies.
How do patients with proctitis usually present?
Patients with proctitis usually present with rectal bleeding, urgency and tenesmus
How do patients with more extensive UC usually present?
Patients with more extensive disease present with loose stool usually associated with rectal bleeding. They may also describe:
Tenesmus
Faecal urgency
Nocturnal defaecation
Mucous discharge
Abdominal pain relieved by defaecation
What does left sided colitis refer to?
Left-sided colitis refers to inflammation distal (below) the splenic flexure.
True or false
UC is characterised by a relapsing and remitting course
True.
True or false
A history of nocturnal defaecation is more suggestive of UC than IBS
True
Prefered investigation for diagnosing UC
Colonoscopy is the preferred test for diagnosing and determining the extent of disease.
However, it should be avoided in severe disease, where an unprepared sigmoidoscopy can be performed if required
Investigations in UC and why
- Basic blood tests
- Stool tests (to exclude infectious etiology)
- Fecal calprotection (It can be useful to distinguish young patients with diarrhoea-predominant IBS.)
- Radiological investigations (X-Ray, CT with contrast if unsure of diagnosis)
- Colonoscopy
What is fecal calprotectin
This is a marker of colonic inflammation
Medical therapies for UC
The optimal treatment strategy varies with the extent of inflammation and can include oral and/or topical therapies and includes:
- 5-ASA drugs (mesalazine)
- Corticosteroids (Sometimes used in active disease, not for maintenance)
- Thiopurines (azathioprine or 6-mercaptopurine)
Rescue therapy include ciclosporin and biologics
Indication of thiopurines
Indications:
- Steroid sparing agents in patients with steroid refractory disease or those - requiring frequent courses of treatment
Patients intolerant of, or failing to respond to, treatment with 5-ASAs
Medical treatment of proctitis
First line treatment is a topical 5-ASA, administered as a suppository and/or enema.
Topical 5-ASAs are more effective than topical steroids, although they can be used in combination.
Medical treatment of left sided UC
This is most effectively treated with a combination of an oral and topical 5-ASA.
Oral or topical 5-ASA monotherapy or topical steroids are less effective than this combination.
Oral corticosteroids can be added if there is a lack of response to the above treatment.
Medical treatment of extensive colitis
Initial treatment should comprise an oral 5-ASA. However, addition of a topical 5-ASA can be added if tolerated.
Add oral corticosteroids if there is a lack of response to the above treatment.
Consider escalation of medical therapy to include immunosuppressants if patients have a poor response or frequent disease relapses despite the treatments outlined above.
Admit any patient with severe colitis to hospital for further assessment and treatment.
CRP and ESR in UC
markers of disease activity (except in ulcerative proctitis where they can often be normal)
