Ulcerative Colitis Flashcards
What is it a subtype of?
Inflammatory bowel disease: ulcerative colitis + Crohn’s disease
What are inflammatory bowel diseases?
Chronic, relapsing, remitting inflammation of the gastrointestinal tract
What do the 2 types of IBD differ in?
Type and location of inflammation
When do the 2 types of IBD commonly present?
They are both lifelong conditions and commonly present in the teens and twenties (25% present in adolescence; median age at diagnosis is 29.5 years)
What, specifically, is ulcerative colitis?
A relapsing and remitting inflammatory disorder of the colonic mucosa (limited to colon/large bowel)
How does the inflammation progress in ulcerative colitis?
Continuous inflammation (only colon): begins at rectum and works proximally
What causes UC?
Inappropriate immune response against (?abnormal) colonic flora in genetically susceptible individuals
Is the appendix involved?
Appendix can be involved
Where might UC affect?
It may affect just the rectum = proctitis (30%)
Or extend to involve part of the colon = left-sided colitis (40%)
Or the entire colon = pancolitis (30%)
What is proctitis?
Inflammation confined to rectum
How does proctitis present?
Frequency, urgency, incontinence, tenesmus
Small volume mucus and blood
Proximal faecal stasis (constipation)
How is proctitis managed?
Reponds to topical therapy
What are the risk factors for UC?
Family history of the condition
HLA associations
3-fold as common in non-smokers (the opposite is true fro Crohn’s disease): symptoms may relapse on stopping smoking
What is the symptoms of UC?
BLOODY DIARRHOEA ± mucus
Abdominal pain (crampy)
Weight loss
Fatigue
What extra-intestinal signs may be seen in a patient with UC?
Clubbing
Primary sclerosing cholangitis
Sacroilitis
How is a diagnosis made?
Bloods for markers of inflammation: normocytic anaemia, increased CRP/platelets, low albumin Stool culture to rule out infection Faecal Calprotectin 0-50ug/g stool = normal 50-200 = equivocal >200 = elevated Colonoscopy and colon mucosal biopsies
What is acute severe colitis?
Acute severe ulcerative colitis is a ‘life threatening medical emergency’ according to NCE 2015 (2% risk of mortality, <1% at specialist IBD centres)
What is the risk of emergency colectomy at admission in patients with ASC?
20-30%
What actually is acute severe ulcerative colitis?
Flare up/sudden worsening or first presentation of ulcerative colitis
What is the presentation of patients with ASC?
These patients look well, self caring and mobilising around ward (young with physiological reserve)
It is defined as 6 or more bloody stools/day AND any of:
- Temperature > 37.8 degrees celsius
- Tachycardia > 90 bpm
- Anaemia (Hb < 105 g/L)
- ESR > 30 mm/h, CRP > 30 mg/L
What are the investigations in patients with ASC?
3-4 serial stool cultures for C. difficile (ensure multiple stool MC&S/CDT to exclude infection)
AXR:
- Toxic dilatation
- Extent of disease: mucosal oedema, lead pipe (loss of haustra in the colon due to inflammation + swelling), proximal faecal loading)
What are the management options in patients with ASC?
- 20-30% risk of emergency colectomy at admission
- Stool chart
- IV glucocorticoids
- LMWH (prophylaxis) - 3x risk of (venous) thrombo-embolism
- Avoid/stop non-steroidal analgesics, opiates, anti-diarrhoeals, anti-cholinergics + ask about OTC drugs
- IV hydration, careful correction of electrolytes - low potassium or magnesium can precipitate toxic megacolon
What are the complications that can arise in patients with ASC?
Toxic megacolon/ dilatation of colon (colonic diameter > 5.5cm):
- Surgical emergency (colectomy)
- Risk of sepsis/shock
- Risk of perforation is high => serious infection and even death
What percentage of patients will require a colectomy within 10 years diagnosis?
20-30%
What are the management aims in patients with ulcerative colitis?
Goal is to induce/achieve then maintain disease remission
In ulcerative colitis what is used in flares to induce remission?
Steroids/5-ASA
Is 5-ASA used in Crohn’s disease?
5-ASA is not effective in Crohn’s disease
What is 5-ASA used for in ulcerative colitis?
Remission induction (1st line therapy) or maintenance (1st line therapy)
How does 5-ASA work?
Reduces inflammation
Topical to colonic mucosa (release mechanisms lead to colonic delivery)
How is 5-ASA given?
PR for distal disease (superior to rectal steroids) or PO for more extensive disease (combine PO + PR if flare)
What is the point in maintenance therapy?
Maintenance treatment reduces number + severity of relapses and reduces CRC risk
How is moderate UC managed?
Induce remission with oral prednisolone (more powerful to reduce inflammation)
Then maintain on 5-ASA
Why are steroids not used for maintenance?
Steroids have adverse side effects => not good for long term (maintenance) use
- Weakened bones
- Cataracts
- Acne
- Weight gain
- Insomnia
- Irritability
What is the next step up treatment used for maintenance?
Immunomodulation: used for maintenance of UC + Crohn’s disease
How does immunomodulation work?
Reduces activity of immune system
Maintains remission if your symptoms haven’t responded to other medicines
How long does immunomodulation take to start working?
Usually take 2-3 months
What are the problems with immunomodulation?
Significant side effects: abdominal pain, hepatotoxicity, pancreatitis and possible long term lymphoma risk and non-melanoma skin cancers
Can check TPMT to assess suitability
What is the next step up maintenance treatment?
Biologics e.g. anti-TNF
What are biologics used?
Used to treat patients intolerant of immune-modulation, or developing symptoms despite an immune-modulator
What does the patient go through before being started on immunomodulation?
Patient is screened before being started on biologic therapy because it dampens down immune response and if they latent disease e.g. hep B/C, HIV, TB it will come to light
Always ensure patient has no contra-indications to treatment
What is an alternative treatment more commonly used in children?
Exclusive elemental feeding can be as effective as steroids
Rests the GI tract
More commonly used in children: avoids slower growth risk that can happen with steroids
8 weeks
Usually nasogastric tube
Compliance difficult
How should mild/moderate flare ups be treated?
At home
Where should severe flare ups be managed?
In hospital to minimise risk of dehydration + potentially fatal complications such as the colon rupturing
What does unwell + >6 motions/day mean?
Admit (acute severe colitis)
What is ulcerative colitis surgery and when is it needed?
Colectomy
This is needed at some stage in around 20% of patients for failure of medical therapy or fulminant colitis with toxic dilatation/perforation
What are the two pathways for surgery?
Emergency: acute severe colitis not responding to 72 hours high dose IV steroids ± anti-TNF biologic ‘rescue’ therapy
Elective: frequent relapses despite medical therapy (recurrent courses of steroids - should not have >2 courses per year), not able to tolerate medical therapy (unacceptable side effects affecting QOL), steroid dependant (relapse prior to or shortly after stopping steroids), patient choice
What is the surgical procedure carried out for UC patients?
Total colectomy + rectal preservation + ileostomy (it is possible that a pouch procedure will be carried out at a later date)
What happens after this procedure?
After total colectomy = end ileostomy (sits in right iliac fossa) + rectal stump (rectum normally calms down)
Subsequently: completion proctectomy (permanent stoma) vs. ileo-anal pouch (rectum is removed)
What is the pouch procedure?
Ileum is made into a j-shaped pouch and connected to the top of the anal canal - the pouch collects waste and allows stool to pass through the anus in a normal bowel movement
What are the pros and cons of the pouch procedure?
Pouches mean stoma reversal and the possibility of long-term continence but pouch opening frequency may still be around 6x/day and recurrent pouchitis can be troublesome (give antibiotics e.g. metronidazole + ciprofloxacin for 2wks)
What are the complications associated with UC?
Acute (emergency):
- Haemorrhage
- Perforation
- Toxic dilatation
Colonic cancer:
- Risk related to disease extent and activity
- Around 5-10% with pan colitis for 20 yrs
- Surveillance colonoscopy
What is Faecal Calprotectin?
Simple, non-invasive test for GI inflammation with high sensitivity, it is released into the GI tract in excess when there is any inflammation there (in general, the degree of elevation is associated with the extent of the inflammation)
What is in the IBD differential diagnosis?
Chronic diarrhoea: malabsorption/malnutrition/IBS
Ileo-caecal TB (don’t see often, common in India)
Colitis must be distinguished from infective, amoebic and ischaemic colitis
