Ulcerative colitis

Question 1

What is ulcerative colitis (UC)?

Answer 1

Ulcerative colitis = chronic relapsing and remitting inflammatory disease affecting the large bowel

o Involves rectum and spreads proximally: proctitis -> proctosigmoiditis -> LHS colitis
o Tends not to spread past ileo-caecal valve
o Continual spread
o Mucosa and submucosa affected

Question 2

What is the aetiology of UC?

Answer 2

Unknown aetiology – many suggested hypotheses
o Genetic susceptibility – C12, C16
o Immune response to bacterial/self-antigens
o Environmental - Sulfate-reducing bacteria found in large numbers in UC
o Altered neutrophil function
o Abnormality in epithelial cell integrity

Question 3

What are the risk factors of UC?

Answer 3

• FH (15%)
• HLA-B27
• Infection - 50% of relapses
• NSAIDs - Can cause a flare up

Not smoking
o Smoking reduces risk by 40%

Question 4

What is the epidemiology of UC?

Answer 4

• Prevalence of 1 in 1500 in developed world
• Higher prevalence in Ashkenazi Jews and Caucasians - More common in western and northern hemispheres
• Uncommon before age of 10
• Peak onset age 20-40
• Equal sex ratio up to age of 40, then higher in males

Question 5

What are the symptoms of UC?

Answer 5

• Rectal bleeding
• Diarrhoea - Stool frequency related to severity of disease
• Blood/mucus in stool
• Abdominal pain - Lower abdominal, crampy
• Arthritis and spondylitis
• Malnutrition
• Abdominal tenderness
• Fever
• Weight loss
• Tenesmus = continual/frequent need to open bowels
• Urgency

Question 6

What are the signs of UC?

Answer 6

• Rectal bleeding
• Arthritis and spondylitis
• Malnutrition
• Abdominal tenderness
• Fever
• Weight loss
• Pallor
• Dehydration
• Clubbing
• Tachycardia
• Blood, mucus and tenderness on DRE

Question 7

What are the first line investigations for UC?

Answer 7

o Stool - Negative culture, WBC present
o Bloods
FBC - Anaemia, leucocytosis
Metabolic panel - Hypokalaemic metabolic acidosis, Elevated sodium, urea, alkaline phosphatase, bilirubin, AST
Hypoalbuminaemia
ESR - Elevated (>30mm/hr suggests severe flare up)
CRP - Elevated

o Plain AXR - Dilated loops with air fluid level secondary to ileus
Toxic megacolon = transverse colon >6cm diameter

Question 8

What are further investigations for UC?

Answer 8

• Diagnostic
Endoscopy = flexible sigmoidoscopy/colonoscopy with biopsies
Loss of vascular marking, diffuse erythema, mucosal granularity
Determines severity, confirms histologically, detects dysplasia
Histology - Mucosal ulcers, Goblet cell depletion, Crypt abscesses

Other investigations
o Serological markers - pANCA = perinuclear antineutrophil cytoplasmic antibody = + in 70%

o Double-contrast barium enema - Mucosal ulceration with granular appearance and filling defects
Loss of haustral pattern
May be dangerous in acute exacerbations due to increased risk of perforation

o CT

Question 9

What is the management of fulminant UC?

Answer 9

Fulminant = severe and sudden = >10 bowel movements, large bleeding, severe systemic toxicity

Admission
IV corticosteroids - Hydrocortisone sodium succinate 100mg IV every 6hrs
IV fluids
Cicosporin/infliximab = immunosuppression
Antibiotics
Parenteral feeding
If needed, colectomy

Question 10

What is the management of non-fulminant UC?

Answer 10

Severe, non-fulminant
Topical/oral mesalazine (5-aminosalicylic acid derivative)
Oral corticosteroids
If needed, colectomy

Mild-moderate, non-fulminant
Mesalazine (oral if extensive/topical if distal)
If needed, corticosteroids

Surgery IF
•	>8 bowel movements a day
•	Pyrexia
•	Tachycardia
•	Dilation on AXR
•	Low albumin, Hb and high platelets, CRP

Ongoing
In remission
o Oral mesalazine

Refractory
o Thiopurines or cyclosporin

Question 11

What are the possible complication of UC?

Answer 11

GI
o	Haemorrhage (3%)
o	Toxic megacolon - Colectomy indicated if patient does not respond with 24-48hrs
o	Perforation
o	Colonic carcinoma (extensive disease >10yrs) (3-5%)
o	Gallstones
o	Stricture
o	Primary sclerosing cholangitis

Extra-GI (10-20%)
o	Uveitis
o	Kidney stones
o	Arthropathy
o	AS
o	Erythema nodosum
o	Osteoporosis
o	Amyloidosis

Question 12

What is the prognosis of UC?

Answer 12

Normal life expectancy
o Increase in mortality in older patients and those who develop complications

Poor prognostic factors = ABCDEF
o	A = albumin <30g/L
o	B = blood PR
o	C = CRP raised
o	D = dilated loops of bowel
o	E = 8+ bowel movements
o	F = fever >38

3-5% develop colonic adenocarcinoma

Benign stricture may rarely cause obstruction