Ulcerative Colitis Flashcards
What is UC
Form of inflammatory bowel disease
Age of presentation is 15-25 years and then another peak at 55-65 yrs
Follows a remitting and relapsing course
What is the pathophysiology of UC
Diffuse continual inflammation of the large bowel, beginning in the rectum and spreading proximally
A portion of the distal ileum can be affected - backwash ileitis
What are the histological changes in UC
inflammation of the mucosa and submucosa
Crypt abscesses
Goblet cell hyperplasia
Pseudopolyps - repeated cycles of ulceration and healing may lead to raised areas of inflammation
What are the clinical features of UC
Insidious in onset
Cardinal feature - bloody diarrhoea with visible blood in stool
most common manifestation is proctitis - PR bleeding with mucus, increase frequency, urgency and tenesmus
dehydration
electrolyte imbalances
Systemic features
malaise
anorexia
low grade fever
What is fulminant colitis
severe UC more than 10 stools a day Continuous bleeding abdominal pain distension Systemic upset - fever and anorexia may be signs of peritonism
What is toxic megacolon
Acute form of colonic distension
diameter >6cm on AXR
Very dilated colon with abdominal distension, fever, shock and abdo pain
Tachycardia, low BP, high temp
Treated by decompressing the bowel or if that doesnt work a colectomy with end ileostomy
ABx given to reduce chance of sepsis ]
Corticosteroids if due to UC
Which classification is used to grade how severe a UC exacerbation is
Truelove and Witts
What would constitute a mild UC exacerbation
<4 stools a day minimal blood No pyrexia No anaemia Pulse <90 ESR <30
What would constitute a moderate UC exacerbation
4-6 stools a day Mild-severe blood No pyrexia pulse <90 no anaemia ESR 30
What would constitute a severe UC exacerbation
>6 stools a day Visible blood Pyrexia Anaemia Pulse >90 bpm ESR >30
What are the extra intestinal manifestations of UC
MSK: Enteropathic arthritis, clubbing
Skin: Erythema Nodosum - tender red papules on patients shins
Eyes: Episcleritis, anterior uveititis, iritis
Hepatobiliary: Primary sclerosing cholangitis - chronic inflammation and fibrosis of the bile ducts
What are the differentials for UC
Crohns disease however UC patients have more bloody diarrhoea IBS Coaliac disease Malignancy
Which investigations are done in UC
Bedside obs
Bloods
FBC - may show anaemia and raised WCC
U+Es - may show dehydration
LFTs - may be deranged in patients on medical treatment
CRP - raised
Clotting - may be deranged in severe attacks due to large inflammatory process affecting coagulation cascade
Imaging
AXR - in acute exacerbations to determine whether toxic megacolon has occurred or perforation (erect CXR needed)
Colonoscopy with biopsy - continuous inflammation with possible ulcers and pseudopolyps (should be avoided in acute severe exacerbations)
Flexi sig may be sufficient
How many biopsies are needed
At least 2 biopsies are required from 5 sites including the rectum and terminal ileum for definitive diagnosis
What are the features of UC on AXR
Mural thickening
thumb printing
Lead pipe colon - in chronic UC best seen on barium studies
Which drugs should be avoided in acute attacks of UC
anti-motility drugs such as loperamide - can precipitate toxic megacolon
How is remission induced in acute flares of UC
A-E assessment Iv access Fluids Nutritional support Prophylactic heparin Corticosteroids Immunosuppressants - azathioprine and mesalazine Biologics can be trialed - infliximab
How is remission induced in mild - moderate (proctitis)
Step 1: topical mesalazine or sulfasalazine Step 2 (if no improvement in 4 weeks): Oral prednisolone and oral tacrolimus
How is remission induced in mild to moderate (extensive inflammation)
Step 1: high oral dose of mesalazine or sulfasalazine
Step 2: Oral prednisolone and Oral tacrolimus
How is severe UC flares put into remission
Step 1: IV corticosteroids and assess the need for surgery
Step 2: add infliximab if no shrt term response
How is remission maintained
Using immunomodulators such as mesalazine and sulfasalazine
Infliximab or othe monoclonal antibody therapy can be used as next line therapies
What further management is offered to patients with UC
Due to increased risk of malignancy - colonoscopic surveillance for people who’ve had the disease for >10 yeas with >1 segment of bowel affected
IBD nurse specialists
Patient support groups
Nutritional support for young people with growth concerns
Abx only for concurrent infection or perianal disease - normally metronidazole or ciprofloxacin
What are the indications for acute surgical treatment in UC
Disease refractory to medical treatment
toxic megaolon
Bowel perforation
May be undertaken to reduce risk of colonic carcinoma
What type of surgery is offered to UC patients
Total proctocolectomy - curative, patient will require an ileostomy
May patients will opt for a sub total colectomy with preservation of the rectum
Some patients may undergo ileal-pouch-anal anastomosis operation, formed from loops of ileum - act as a reservoir for intestinal contents
What re the complications of UC
Toxic megacolon - serious complication, dilation of the colon to at least 6cm in diameter on AXR
Colonic malignancy
Osteoporosis - should be regularly assesed for fracture risk
Pouchitis - inflammatio of the ileal pouch - abdo pain, bloody diarrhoea and nausea. Treated with metronidazole and ciprofloxacin
What are the short term side effects of steroids
Weight gain Increase in appetite Water retention Acne Thin skin that bruises easily Mood swings and mood changes Reduced immune system - may get more infections
What are the long term side effects of steroids
Osteoporosis Thin skin muscle weakness delayed wound healing Cushings syndrome Diabetes High BP Eye conditions e.g. glaucoma Stomach ulcers Mental health problems Addisonian crisis if steroids are stopped suddenly - suppresses HPA axis
