Ulcerative Colitis

Question 1

What is UC and what anatomical location does it affect?

Answer 1

Inflammatory disorder of the colonic mucosa.

• Proctitis - 30%
• Left sided colitis - 40%
• Entire colon (pancolitis) - 30%

Question 2

How is the inflammatory process different to Crohns disease in UC?

Answer 2

The inflammation is most often confined to the submucosa.

Question 3

At what age does UC usually present?

Answer 3

~20-40 years old

Question 4

What effect does smoking have on UC?

Answer 4

It is protective. UC is 3x more common in non-smokers

Question 5

What are the symptoms of UC?

Answer 5

Episodic/chronic diarrhoea

Abdominal pain

Bowel urgency/Tenesmus

Acute exacerbations: weight loss, fever, malaise, anorexia

Question 6

What investigations would you perform if you thought a patient had UC?

Answer 6

U&E, LFT, CRP

Blood culture and stool culture

FBC, ESR

Faecal calprotectin

AXR: shows mucosal thickening/islands

Flexi sig: acutely assess and take a biopsy

Colonoscopy: This is carried out once controlled to define disease extent.

Question 7

How is UC severity assessed based on frequency of bowel movements?

Answer 7

<4 - mild UC
5 - moderate UC
>6 - severe UC

Other factors are considered including temperature, rectal bleeding, resting pulse, Hb and ESR

Question 8

Which extra-intestinal signs may you find with UC?

Answer 8

• Erythema nodosum
• Pyoderma gangrenosum
• Finger clubbin
• Apthous ulcers
• Ankylosing spondylitis
• Episcleritis, iritis, conjunctivitis
• Large joint arthritis

Question 9

Name 2 complications of acute UC?

Answer 9

Venous thromboembolism - prophylaxis should always be given to patients regardless of rectal bleeding

Toxic dilatation of the colon - risk of perforation.

Question 10

What is the management for UC patients?

Answer 10

Mild disease: Mesalazine PR for more distal disease, PO for more extensive disease. This is for induction and maintenance of remission. Consider topical steroid foams PR in addition.

Moderate disease: Oral prednisolone 40mg/d for 1 week. Then taper down by 5mg/week for the following 7 weeks. Maintenance on mesalazine.

Severe disease: IV fluids, IV steroids, thromboembolism prophylaxis.

Question 11

When would you consider immunomodulation therapy in a patient with UC?

Answer 11

• If a patients UC flares on steroid tapering

* If a patient has >2 flare ups in a year.

Question 12

What is the first line immunomodulation for patients with recurrent flare ups not controlled with steroids?

Answer 12

Azathioprine 2-2.5mg/kg/d PO

Question 13

What Biologic therapy can be used if immunomodulation is not tolerated/ineffective?

Answer 13

Infliximab

Question 14

When is surgery indicated in a patient with UC?

Answer 14

• A patient with toxic dilatation of the colon

Question 15

What types of surgery can be offered to a patient with UC?

Answer 15

• A subtotal colectomy and terminal ileostomy
• Completion proctectomy
• Ileo-anal pouch - this is reversible however high output. Pouch change required 6 x a day and recurrent pouchitis is troublesome

Question 16

What is erythema nodosum?

Answer 16

Inflammation of the sub-cutaneous fat leading to discrete erythematous lesions commonly found on the shins.

Question 17

Other than UC, what causes Erythema Nodosum?

Answer 17

• Pregnancy
• Infection - eg. Streptococci, TB, Brucellosis
• Drug induced - Penicillin, COCP
• Malignancy/lymphoma

Question 18

What is pyoderma gangrenosum?

Answer 18

A skin presentation commonly found on the shins. Starts off as a small red lesion and develops into deep red necrotic ulcers

Question 19

What causes Pyoderma gangrenosum?

Answer 19

• Idiopathic in 50% of patients
• IBD
• Rheumatoid arthritis/SLE
• Myeloproliferative disorders
• Primary biliary cirrhosis