Ulcerative Colitis

Question 1

Definition

Answer 1

Chronic relapsing and remitting inflammatory disease affecting the large bowel

Question 2

Aetiology

Answer 2

• UNKNOWN
• Possible genetic susceptibility

• Other factors involved: immune response to bacterial or self-antigens, environmental
factors, altered neutrophil function and abnormality in epithelial cell integrity

• Positive family history - 15% of patients

• Associations:
o pANCA
o Primary sclerosing cholangitis (70% of patients with PSC have UC)

Question 3

Epidemiology

Answer 3

• Higher prevalence in:
o Ashkenazi jews
o Caucasians

• Uncommon before the age of 10 yrs
• Peak onset: 20-40 yrs
• Equal sex ratio up to the age of 40 yrs (higher in males from then on)

Question 4

Presenting symptoms

Answer 4

• Bloody or mucous diarrhoea (stool frequency depends on severity of disease)
• Tenesmus and urgency
• Crampy abdominal pain before passing stool
• Weight loss
• Fever
• Extra-GI manifestations (e.g. uveitis, scleritis, erythema nodosum, pyoderma gangrenosum)

Question 5

Signs on physical examination

Answer 5

• Signs of iron deficiency anaemia (e.g.
conjunctival pallor)
• Dehydration
• Clubbing
• Abdominal tenderness
• Tachycardia
• Blood, mucus and tenderness on PR
examination
• Extra-GI manifestations (see presenting symptoms)

Question 6

Investigations (bloods)

Answer 6

o FBC:
• Low Hb
• High WCC
o High ESR or CRP
o Low albumin

o NOTE: X-match if there is severe blood loss

Question 7

Investigations (other)

Answer 7

• Stool
o Infectious colitis is a differential diagnosis so a stool culture maybe useful
o Faecal calprotectin allows differentiation of IBS from IBD
• It is raised in inflammatory processes (i.e. IBD)
• Both IBS and IBD can present with long-term diarrhoea

• AXR
o Rule out toxic megacolon

• Flexible Sigmoidoscopy or Colonoscopy (and biopsy)
o Determines severity
o Histological confirmation
o Detection of dysplasia

• Barium Enema
o Shows mucosal ulceration with granular appearance and filling defects (due to pseudopolyps)
o Narrowed colon
o Loss of haustral pattern - leadpipe appearance (right)
o Colonoscopy and barium enema may be DANGEROUS
during an acute exacerbation - risk of perforation

Question 8

Markers of disease activity

Answer 8

o Decreased Hb
o Decreased albumin
o Increased ESR and CRP
o Diarrhoea frequency:
• < 4 = mild
• 4-6 = moderate
• 6+ = severe
o Bleeding
o Fever

Question 9

Management plan (acute exacerbation)

Answer 9

o IV rehydration
o IV corticosteroids
o Antibiotics
o Bowel rest
o Parenteral feeding may be necessary
o DVT prophylaxis
o If toxic megacolon - the patient is likely to need a proctocolectomy because toxic megacolon has a high mortality

Question 10

Management plan (mild)

Answer 10

o Oral or rectal 5-ASA derivatices (e.g. mesalazine, olsalazine, sulphasalazine)
and/or rectal steroids

Question 11

Management plan (moderate to severe)

Answer 11

o Oral steroids
o Oral 5-ASA
o Immunosuppression (with azathioprine, cyclosporine, 6-mercaptopurine or
infliximab (anti-TNF monoclonal antibody))

Question 12

Management plan (advice)

Answer 12

o Patient education and support
o Treat complications
o Regular colonoscopic surveillance

Question 13

Management plan (surgical)

Answer 13

o If medical treatment fails, presence of complications or to prevent colonic
carcinoma

o Procedures:
• Proctocolectomy with ileostomy
• Ileo-anal pouch formation

Question 14

Possible complications (gastrointestinal complications)

Answer 14

o Haemorrhage
o Toxic megacolon
o Perforation
o Colonic carcinoma
o Gallstones
o Primary sclerosing cholangitis

Question 15

Possible complications (extra-gastrointestinal)

Answer 15

o Uveitis
o Renal calculi
o Arthropathy
o Sacroiliitis
o Ankylosing spondylitis
o Erythema nodosum
o Pyoderma gangrenosum 
o Osteoporosis (from chronic steroid use)
o Amyloidosis

Question 16

Prognosis

Answer 16

• Normal life expectancy

• Poor prognostic factors:
o Low albumin (< 30 g/L)
o PR blood
o Raised CRP
o Dilated loops of bowel
o 8+ bowel movements per day
o Fever