ULCERATIVE COLITIS

Question 1

WHAT IS THE PATHOPHYSIOLOGY OF UC?

Answer 1

• inflammation of the large bowel, starts in large bowel and moves proximally

Question 2

WHAT AGE GROUPS DOES IT USUALLY AFFECT?

Answer 2

• bimodal presentation

- 15 to 25 years and 55 to 65 years

Question 3

WHAT ARE THE MICROSCOPIC CHANGES OF UC?

Answer 3

• crypt abscess

Question 4

WHAT ARE THE MACROSCOPIC CHANGES OF UC?

Answer 4

• continuous inflammation (no skip lesions)
• only affects mucosa
• pseudopolyps - projecting mass of scar tissue
• ulcers

Question 5

WHAT ARE THE CLINICAL FEATURES OF UC?

Answer 5

• bloody diarrhoea
• PR bleeding and mucos discharge
• Increased frequency
• Faecal urgency - inability to wait to open bowels
• Tenesmus - cramping rectal pain, giving feeling you need to go toilet, even if you have already had one
• Systemic - malaise, anorexia, pyrexia

Question 6

WHAT INVESTIGATIONS ARE THERE FOR UC?

Answer 6

1) Stool sample - faecal calprotectin (raised in IBD, unchanged in IBS)
2) Blood test - FBC (anaemia), CRP (inflammation), LFT
3) Colonoscopy with biopsy - definitive diagnosis (avoided in acute exacerbations)

Question 7

WHAT INVESTIGATIONS ARE DONE IN ACUTE EXACERBATIONS?

Answer 7

1) AXR/ CT imaging - shows mural thickening (thumbprinting), toxic megacolon, bowel perforation

Question 8

WHAT IS THE MANAGEMENT FOR AN ACUTE ATTACK (INDUCE REMISSION) OF UC?

Answer 8

1) fluid resuscitation
2) nutritional support
3) prophylactic heparin (flares cause prothrombotic state)
4) Corticosteroid therapy - oral prednisolone and tacrolimus, no effect then step up to infliximab/ IV hydrocortisone
5) Immunosuppressive agents - topical mesalazine and sulfasalazine, no effect then step up to oral

Question 9

WHAT MANAGEMENT TO MAINTAIN REMISSION?

Answer 9

1) Immunomodulators - mesalazine and sulfasalazine
2) Colonoscopic surveillance - risk of colorectal malignancy
3) Enteral nutritional support

Question 10

WHAT SURGICAL MANAGEMENT IS AVAILABLE?

Answer 10

• provided to those not responding to medical treatment and those experiencing complications
  1) Total proctocolectomy (rectum and all or part of colon) with ileostomy

Question 11

WHAT ARE THE COMPLICATIONS OF UC?

Answer 11

• toxic megacolon
• bowel perforation
• colorectal carcinoma
• osteoporosis

Question 12

WHAT ARE THE FEATURES OF TOXIC MEGACOLON AND MANAGEMENT?

Answer 12

• severe abdominal pain
• abdominal distension
• pyrexia
• requires ASAP bowel decompression

Question 13

WHAT ARE THE DIFFERENTIAL DIAGNOSIS OF UC?

Answer 13

• Crohn’s disease
• IBS
• Coeliac disease
• Malignancy

Question 14

WHAT SHOULD BE GIVEN TO PATIENTS ADMITTED TO HOSPTIAL WITH ACUTE IBD AND WHY?

Answer 14

• prophylactic heparin due to high risk of venous thromboembolic event as a result of hypercoagulability.