Ulcerative colitis

Question 1

What is ulcerative colitis?

Answer 1

An inflammatory bowel disease characterised by diffuse inflammation of the colonic mucosa and a relapsing remitting course. It normally involves the rectum and extends proximally to affect a variable length of colon.

Question 2

What are the risk factors of UC?

Answer 2

Family history
HLA B27
infection
NSAIDs
Not smoking or former smoker

Question 3

What is the epideiology of UC?

Answer 3

Incidence: 1-24 in 100,000 people per year (stable)
Highest in Scandinavia and North Europe
Prevalence: 1 in 1000 (increased recently)
West > East
Slightly more common in men than woman
aged 20-40 and 60 (uncommon <10)

Question 4

What are the signs and symptoms of UC?

Answer 4

Rectal bleeding
Diarrhoea
Blood in stool

Also: Abdominal pain, athritis/spondylitis, malnutrition, abdominal tenderness
Maybe: fever, weight loss, constipation, skin rash, uveitis/ episcleritis, pallor

Question 5

What investigations would you do for UC?

Answer 5

Stool- negative culture/ CDiff toxins, WBC present, elevated faecal calprotectin

FBC- variable anaemia, leukocytosis, thrombocytosis

Metabolic panel- hypokalaemic metabolic acidosis; elevated sodium and urea; elevated alkaline phosphatase, bilirubin, aspartate aminotransferase, and alanine aminotransferase; hypoalbuminaemia

ESR- variable degree of elevation, although >30mm/hour is suggestive of a severe flare-up

CRP- variable degree of elevation

Radiograph (abdo)- dilated loops with air-fluid level secondary to ileus; free air is consistent with perforation; in toxic megacolon, the transverse colon is dilated to ≥6 cm in diameter

flexible sigmoidoscope- findings are as in colonoscopy, but examination is limited to distal colon

colonoscopy- rectal involvement, continuous uniform involvement, loss of vascular marking, diffuse erythema, mucosal granularity, fistulas (rarely seen), normal terminal ileum (or mild ‘backwash’ ileitis in pancolitis)

biopsies-continuous distal disease, mucin depletion, basal plasmacytosis, diffuse mucosal atrophy, absence of granulomata, and anal sparing

Question 6

What is the management of UC?

Answer 6

> Corticosteroids
> Mesalazine
> Infliximab
> vedolizumab
> tofacitinib
> Ciclosporin
> Colectomy

Question 7

What are the complications of UC?

Answer 7

Toxic megacolon
Perforation
Infection
Massive GI bleed 
colonic adenocarcinoma
benign stricture
inflammatory pseudopolyps
PSC
DALM

Question 8

What is the prognosis of UC?

Answer 8

Possible increased mortality but not confirmed
Increased mortality in surgical intervention
Toxic megacolon most common cause of death