Ulcerative colitis

Question 1

Describe ulcerative colitis?

Answer 1

• Most common form of IBD
• Caucasians, bimodal (15-25, 55-65), males and females equally
• Relapsing and remitting

Question 2

What can a severe fulminant exacerbation of UC result in?

Answer 2

• Severe systemic upset
• Toxic megacolon
• Colonic perforation
• Death

Question 3

What is pictured here?

Answer 3

• Histology of bowel segment in UC
  
  • Shows non-granulomatous inflammation with crypt abscess

Question 4

Describe the pathophysiology of ulcerative colitis?

Answer 4

• Interaction between genetic factors and environmental triggers
• Diffuse continual mucosal inflammation of the large bowel
• Inflammation of mucosa and submucosa

Question 5

Risk factors for UC?

Answer 5

• Positive family history
• Smoking is PROTECTIVE against UC

Question 6

What is backwash ileitis?

Answer 6

• Portion of distal ileum is affected by UC
• Ileocaecal valve is not competent

Question 7

Describe the differences between UC and Crohns?

Answer 7

Question 8

What are the clinical features of UC?

Answer 8

• Insidious onset
• Cardinal feature is bloody diarrhoea*
• Proctitis, PR bleeding, mucus discharge
• Systemic symptoms: malaise, anorexia, low-grade pyrexia

Question 9

Describe the grading of UC?

Answer 9

• Truelove and Witt criteria

Question 10

Describe the extra-intestinal manfiestations of UC?

Answer 10

• MSK
  
  • Arthritis, clubbing
• Skin
  
  • Erythema nodosum
• Eyes
  
  • Episcleritis, anterior uveitis, iritis
• Hepatobilary
  
  • Primary sclerosing cholangitis

Question 11

What is PSC?

Answer 11

Chronic inflammation and fibrosis of the bile ducts

Question 12

Differentials for UC?

Answer 12

• Crohns
• Chronic infections (TB, schistosomiasis, giardiasis)
• Mesenteric ischaemia
• Radiation colitis

Question 13

Investigations into someone with suspected UC?

Answer 13

• FBC, U&Es, CRP, LFTs, clotting
• Faecal calprotectin
• Stool sample with microscopy and culture
• Colonscopy with biopsy (definitive diagnosis)
• AXR or CT (assess for perforation, toxic megacolon)

Question 14

What are the AXR features of UC flares?

Answer 14

• Mural thickening and thumb printing
• Chronic cases:
  
  • Lead pipe colon

Question 15

Describe the management of UC?

Answer 15

• Avoid anti-motility agents as they can cause toxic megacolon
• Fluid resus, nutritional support, prophylactin heparin
• Induce remission:
  
  • Corticosteroids and immunosuppressives
• Maintaining remission:
  
  • 1st line: Immunomodulators
    
    • Mesalazine, sulfasalazine
  • 2nd line: Monoclonal antibody therapy
• Surgical management may be required

Question 16

Describe the step wise approach for inducing remission in UC?

Answer 16

Question 17

What are the indications for acute surgical treatment of UC?

Answer 17

• Disease refractory to medical management
• Toxic megacolon
• Bowel perforation

Question 18

Describe the surgical management of UC?

Answer 18

• Total proloctocolectomy is curative
  
  • Patient will require ileostomy
• Subtotal colectomy with preservation of the rectum

Question 19

Complications of UC?

Answer 19

• Toxic megacolon
• Colorectal carcinoma
• Osteoporosis
• Pouchitis

Question 20

Describe toxic megacolon as a complication of UC?

Answer 20

• Severe abdominal pain on presentation
  
  • Distension, pyrexia, systemic toxicity
• Decompression of bowel is required due to perforation risk