Ulcerative Colitis

Question 1

What is UC? What course does UC follow?

Answer 1

UC is an inflammatory disorder of the colonic mucosa beginning in rectum and spreading proximally
Remitting and relapsing course

Question 2

What part of the GI tract does UC affect?

Answer 2

Large bowel - Rectum and colon only.

Unless ileocaecal valve is incompetent - then backwash ileitis

Question 3

What causes UC?

Answer 3

Inappropriate immune response against colonic flora in genetically susceptible individuals.

Question 4

Describe site involvement and inflammation in UC.

Answer 4

Large bowel only

Mucosa only - continuous inflammation

Question 5

Describe microscopic changes in UC

Answer 5

Crypt abscess formation
Reduced golet cells
Non-granulomatous inflammation

Question 6

Describe macroscopic changes in UC

Answer 6

Continuous inflammation (proximal from rectum)
Pseudopolyps and ulcers may form

Question 7

Describe the onset and clinical features of UC

Answer 7

Insidious onset of episodic/chronic diarrhoea ± blood/mucus
Crampy, abdominal discomfort
Proctitis - PR bleeding, mucus discharge, increased frequency, urgency of defecation and tenesmus - continuous, recurrent inclination to evacuate the bowels

More widespread colonic involvement - bloody diarrhoea with features of dehydration and electrolyte imbalance

Systemic: malaise, anorexia, fever, weight loss

Question 8

What would you suspect if the patient complains of severe abdominal pain and demonstrates systemic upset or signs of peritonism?

Answer 8

Fulminant colitis (severe)
Toxic megacolon
Colonic perforation

Question 9

What signs can be present if UC?

Answer 9

In acute severe UC - fever, tachycardia, tender distended abdomen

Extraintestinal signs
MSK - arthritis, nail clubbing
Slin - erythema nodosum (tender red/purple nodules found typically on shins)
Eyes - episcleritis, anterior uveitis
HPB - primary sclerosing cholangitis - chronic inflammation and fibrosis of bile ducts

Question 10

How can UC severity be assessed?

Answer 10

Truelove and Wii criteria
No. of bowel movmeemnts
Blood in stool
Pyrexia
Pulse > 90
Anaemia
ESR

Question 11

What are Ddx for UC?

Answer 11

Crohn's
Chronic infections - schistosomiasis, giardiasis, TB
Mesenteric ischaemia
IBS
Malignancy
Coeliac

Question 12

What tests for bloody diarrhoea?

Answer 12

FBC, ESR, cRP, U&E, LFT , blood cultures
Stool MC&S: C. diff, Campylobacter, Slamonella, shigella, E.coli
Faecal calprotectin: marker of GI inflammation
AXR: no faecal shadows, mucosal thickening, colonic dilatation

Definitive diagnosis: colonoscopy with biopsy (at least two biopsies required from five sites, including rectum and terminal ileum.

Question 13

What is the definitive method of diagnosis for UC? What is seen?

Answer 13

Colonoscopy with biopsy
At least 2 biopsies are required from five sites including rectum and terminal ileum

Continuous inflammation with possible ulcers and pseudopolyps

Flexible sigmoidoscopy may be sufficient
Full colonoscopy once controlled to define disease extent

Question 14

What are the goals of UC treatment?

Answer 14

Induce and maintain remission

Question 15

How is remission induced in UC?

Answer 15

Corticosteroid therapy and immunosuppressive agents - mesalazine/azathioprine

Question 16

How are acute attacks treated?

Answer 16

Fluid resuscitation, nutritional support, prophylactic heparin

Question 17

How is mild/moderate UC treated (proctitis)

Answer 17

1. Topical mesalazine or sulfasalazine

2. Add oral prednisolonis + oral tacrolimus

Question 18

How is mild/moderate UC with extensive inflammation treated?

Answer 18

High oral dose mesalazine/sulfasalazine

Add oral predinisolone/oral tacrolimus

Question 19

What are side effects of 5-ASA/mesalazine?

Answer 19

Rash, haemolysis, hepatitis, pancreatitis, paradoxical worsening of colitiis

Question 20

How should 5-ASA/mesalazine be monitored?

Answer 20

FBC, U&E, at start, then 3 months, then annually

Question 21

How should severe UC be managed?

Answer 21

Admit for IV hydration/electrolyte replacement, VTE prophylaxis, Stool MC&S to check for infection
IV steroids (hydrocorticsone)

Add infliximab if no short-term response

Assess for surgery - if fails to improve then urgent colectomy

Question 22

How is remission maintained?

Answer 22

Immunomodulators - mesalazine, sulfasalazine

Infliximab or alternative monoclonal antibody to TNF-alpha therapy can be used as next line therapies to maintain remission with recurrent symptoms

Colonoscopic surveillance if offered to patients who have had UC > 10 years with >1 segment of bowel affected

Question 23

What is the indication for immunomodulatik?

Answer 23

Patients flare on steroid tapering or require 2 or more courses of steroids a year

Question 24

What are the side effects of azathioprine?

Answer 24

Nausea, abdopain, pancreatitis, leucopenia, abnormal LFTs

Question 25

What are the indications for surgical management for UC?

Answer 25

Disease refractory to medical management
Toxic megacolon
Bpowel perforation
Reduce risk of colonic carcinoma if dysplastic cells are detected

Question 26

What is the surgical management for UC?

Answer 26

Total protocolectomy is curative (With patient requiring ileostomy)

many patients will initially undergo sub-total colectomy and terminal ileostomy with preservation of the rectum

Some patients undergo ileo-anal pouch anastomosis involving formation of a pouch from loops of ileum that is anastomosed to the anus, aiming to achieve faecal continence

Question 27

What are the complications of UC?

Answer 27

Toxic megacolon - serious complication of UC characterised by dilatation of the colon to at least 6 cm on AXR
- severe abdo pain, abdominal distension, pyrexia, systemic toxicity - decompression of bowel is requires ASAP due to high risk of perforation

Colorectal carcinoma

Osteoporosis

Pouchitiis - inflammation of ill pouch - abdominal pain, bloody diarrhoea, nausea - treat with metronidazole and ciprofloxacin for 2 weeks

Question 28

How many motions/day for mild/moderate/severe? Rectal bleeding? Temperature?
Pulse
Hb?
ESR?

Answer 28

4, 5, 6
Small, moderate, large
Apyrexia, 37.1-37.8, >37.8
<70, 70-90,>90
>110, 105-110, <105
<30, - , >30