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- Y6 Gastrointestinal > Ulcerative colitis > Flashcards

Ulcerative colitis Flashcards

1
Q

Define ulcerative colitis.

A

Chronic relapsing and remitting inflammatory disease affecting the large bowel.

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2
Q

How common is UC?

A
  • 1/1500
  • Higher prevelance in Ashkenazi Jews, caucasians
  • Uncommon before age 10, peak onset 20-40years
  • Equal sex ratio up to 40yrs then higher in males
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3
Q

What are the risk factors for UC?

A
  • FH of IBD
  • HLA-B27
  • Infections
  • NSAID use can cause flare up of disease in some
  • Non-smoker or former smoker
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4
Q

What is the aetiology of UC?

A

Unknown

Suggested that:

  • genetic suscpetibility (Chr12, 16)
  • Immune response to bacterial/self-antigens
  • Environmental factors
  • Altered neutrophil function
  • Abnormal epithelial cell integrity

Associated with raised serum pANCA + PSC

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5
Q

What part of the GI tract is affected by UC?

A

It may affect:

  • just the rectum (proctitis, as in ~30%)
  • or extend to involve part of the colon (left-sided colitis, in ~40%)
  • or the entire colon (pancolitis, in ~30%).

It ‘never’ spreads proximal to the ileocaecal valve (except for backwash ileitis).

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6
Q

What is the pathophysiology of UC?

A
  • Usually affects mucosa only - punctate ulcers may extend deep into the lamina propria
  • Formation of crypt abscesses and a coexisting depletion of goblet cell mucin
  • Hyperaemic/haemorrhagic colonic mucosa ± pseudo-polyps formed by inflammation.
  • Bowel wall is generally of normal thickness - but oedema , accummulation of fat and hypertrophy of muscle layer may give it impression of thickening.
  • Acute severe colitis -→ fulminant colitis or toxic megacolon (thin-walled, dilated colon that can eventually become perforated)
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7
Q

How is UC classified?

A

Left sided colitis - inflammation up to splenic flexure

Extensive colitis - inflammation beyond splenic flexure

Or Montreal classification:

  • E1 (ulcerative proctitis): involvement limited to the rectum (proximal extent of inflammation is distal to the rectosigmoid junction)
  • E2 (left-sided UC, also called distal UC): involvement limited to a portion of the colorectum distal to the splenic flexure
  • E3 (extensive UC, also called pancolitis): involvement extends proximal to the splenic flexure.
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8
Q

What is the criteria for diagnosis of UC?

A

Truelove and Witts criteria

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9
Q

How do you classify mild, moderate and severe UC?

A

Episodic or chronic diarrhoea (± blood & mucus); crampy abdominal discomfort; bowel frequency relates to severity; urgency/tenesmus≈proctitis. Systemic symptoms in attacks: fever, malaise, anorexia, ↓weight.

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10
Q

What is the typical presentation of UC?

A
  • Bloody/mucous diarrhoea (stool frequency related to severity of disease)
  • Tenesmus
  • Urgency
  • Crampy abdo pain before passing stool
  • Weight loss
  • Fever
  • Symptoms of extra GI manifestations - uveitis, episcleritis, erythema nodosum, pyoderma gangrenosum, arthritis, ankylosing spondylitis.
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11
Q

What are the signs of UC on examination?

A
  • Signs of Fe deficiency anaemia - pallor
  • Dehydration
  • Clubbing
  • Abdo tenderness
  • Tachycardia
  • Blood, mucous, tenderness on DRE
  • Signs of extra GI manifestations - Clubbing; aphthous oral ulcers; erythema nodosum; pyoderma gangrenosum; conjunctivitis; episcleritis; iritis; large joint arthritis; sacroiliitis; ankylosing spondylitis; psc; nutritional deficits.
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12
Q

What investigations would you do for UC?

A

Bloods:

  • FBC - low Hb, high WCC
  • ESR, CRP - raised
  • U&E -
  • LFTs- low albumin
  • Blood culture
  • Serological - about 70% of patients with UC have positive pANCA; about 70% of patients with CD have positive ASCA

Stool

  • Stool MC&S - infectious colitis is a Ddx
  • CDT
  • Faecal calprotectin - marker for disease severity

Imaging

  • AXR - rule out toxic megacoon
  • Flexible sigmoidoscopy/colonoscopy + rectal biopsy - determines, severity, histological confirmation, detection of dysplasia.
  • Double-contrast barium enema - fine granular appearance to diffuse ulceration of bowel. NB this test may precipitate toxic megacolon
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13
Q

What type of endoscopy would you do in severe UC disease?

A

Only sigmoidoscopy in severe disease as colonoscopy has risk of perforation.

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14
Q

What might a colonoscopy in UC show?

A
  • 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)
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15
Q

What is the definition of a severe attack of UC?

A

Definition

  • Stool frequency: >6 stools/day with blood +++
  • Fever: >37.5°C
  • Tachycardia: >90 b.p.m.
  • Erythrocyte sedimentation rate: >30 mm/h
  • Anaemia: <100 g/L haemoglobin
  • Albumin: <30 g/L
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16
Q

What is toxic megacolon?

A
  • A serious complication of acute severe colitis
  • AXR shows dilates thin walled colon with diameter >6cm
  • Gas-filled and contains mucosal islands
  • Impending perforation and high mortality (15-25%)
  • Urgent sugery within 48hrs
  • Ddx: infectious colitis e.g. C difficile, cytomegalovirus
17
Q

What are the complications of UC?

A

GI - haemorrhage, toxic megacolon, perforation, infection, colonic carcinoma (in those with extensive disease for >10 years), gallstones, PSC (unknown aetioligy, check LFTs every year)

Extra-gastrointestinal manifestations (10-20%) - uveitis, renal calculi, arthropathy, sacroiliitis, ankylosing spondylitis, erythema nodosum, pyoderma gangrenosum, osteoporosis (from steroids), amyloidosis.

18
Q

What is the management of an acute attack of UC?

A

Management:

  • Admit
  • Exclude infection
  • Do endoscopy
  • IV fluids
  • VTE prophylaxis
  • IV hydrocortisone 100 mg QDS
  • Monitor: stool frequency, AXR, bloods (FBC, CRP, albumin)

Other:

  • Bowel rest, parenteral feeding
  • Immunosuppression - cyclosporine, 6-mercaptopurine, azathioprine, infliximab (anti-TNF monoclonal antibody)
  • Monitor fluid balance and vital signs closely
  • If toxic megacolon develops, low threshold for proctocolectomy and ileostomy as perforation has high mortality
19
Q

What medications are used for treatment of mild-moderate UC?

  1. proctitis only
  2. procto-sigmoiditis and left-sided UC
  3. extensive disease
A

Proctitis

  • topical 5-ASA (rectal mesalazine has been shown to be superior to rectal steroids and oral 5-ASA)
  • if no remission in 4 weeks -→ +oral 5-ASA
  • if no remission still -→ +topical /oral corticosteroid

Proctosigmoiditis and left-sided UC

  • topical 5-ASA
  • if no remission in 4 weeks -→ +high-dose oral 5-ASA OR high-dose oral 5-ASA + topical corticosteroid
  • if no remission still -→ stop topicals, oral 5-ASA + oral corticosteroid

Extensive

  • topical 5-ASA + high-dose oral 5-ASA
  • if no remission in 4 weeks -→ stop topicals, high-dose oral 5-ASA + oral corticosteroid
20
Q

What is the treatment of severe colitis in UC?

A
  • IV corticosteroids 1st line (IV ciclosporin if steroids are CI)
  • If no improvement after 72hrs -→ add IV ciclosporin OR consider surgery
21
Q

What treatment is used for maintaining remission in mild-moderate UC?

A

Proctitis and proctosigmoiditis:

  • topical 5-ASA alone daily OR
  • topical + oral 5-ASA
  • oral 5-ASA

Left-sided and extensive UC

  • low dose oral 5-ASA
22
Q

What is the treatment used for maintaining remission following a severe relapse or 2 or more exacerbations in the past year?

A

Oral azathioprine

OR oral mercaptopurine

23
Q

Is methotrexate used in UC?

A

No (unlike in Crohn’s)

24
Q

Are probiotics used in UC?

A

There is some evidence that probiotics may prevent relapse in patients with mild to moderate disease

- Y6 Gastrointestinal (70 decks)

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