Ulcerative Colitis

Question 1

Define Ulcerative Colitis

Answer 1

Chronic relapsing and remitting inflammatory bowel disease that affects the rectum and colon

Question 2

Aetiology of Ulcerative Colitis

Answer 2

Unknown

Seems to occur in genetically susceptible people in response to environmental trigger

Question 3

Pathophysiology of Ulcerative Colitis

Answer 3

Most cases arise in the rectum (proctitis)
Some may get terminal ileum due to incompetent ileocaecal valve or backwash ileitis
Actual bowel wall thin, but appears thick due to oedema, fat accumulation and muscle hypertrophy
Only involves the mucosa/submucosa - formation of crypt abscesses and depletion of goblet cell mucin + ulcer formation + pseudopolyps

Question 4

RF of Ulcerative Colitis

Answer 4

FMHx
HLA-B27
Infection
NSAIDs, non-smokers/former smokers

Question 5

Presenting symptoms of Ulcerative Colitis

Answer 5

Diarrhoea: usually bloody
Rectal bleeding: intermittent, mucous passage
Abdominal pain and tenderness: cramps, severe if toxic megacolon
Arthritis + spondylitis
Fever
Weight loss
Constipation

Children - Failure to thrive + growth retardation

Question 6

Signs of Ulcerative Colitis

Answer 6

Skin rash (erythema nodosum and pyoderma gangrenosum)
Uveitis and episcleritis
Pallor
Dehydration
Clubbing
Tenderness
Tachycardia

Question 7

Investigations for Ulcerative Colitis

Answer 7

Colonoscopy/sigmoidoscopy: Rectal involvement, continuous and uniform, loss of vascular markings, diffuse erythema
Biopsy: Mucosal ulcers, goblet cell and mucin depletion, crypt abscesses, mucosal atrophy (ONLY mucosal and su-mucosal)

Stool sample: negative culture, WBC present, elevated faecal calprotectin

FBC: anaemia, leukocytosis, thrombocytosis
LFTs: Elevated sodium, urea, ALP/ALT/AST/Bilirubin (PSC), Reduced albumin
CRP/ESR: raised

AXR: Dilated loops with air-fluid level secondary to ileus + thumb-printing, free air (perforation), transverse cololon dilation >6cm (toxic megacolon)
Double-contrast barium enema: lead pipe apperanc

Question 8

What are Flares of Ulcerative Colitis scored/marked by and what are the markers of activity

Answer 8

Truelove and Witt’’s severity index

Markers: 
↓Hb
↓albumin
↑ESR/CRP
Diarrhoea frequency (<4 a day = mild, 
>6 days = severe)
Bleeding
Fever

> 6 movements a day + blood = severe

Question 9

Management of acute severe Ulcerative Colitis

Answer 9

1. Admit + IV corticosteroids e.g. IV hydrocortisone
2. IV fluids
3. Suboptimal response - ciclosporin/infliximab
4. Colectomy if not response to steroids (24-48h) or abx (3 days)

Question 10

Management of Non-fulminant acute Ulcerative Colitis

Answer 10

1. Rectal mesalazine 1000mg sat night
2. Oral prednisolone 30-40mg ± tacrolimus
3. Suboptimal -> fulminant management

Question 11

Management of chronic Ulcerative Colitis

Answer 11

Induce Remission:

1. Mesalazine (5-ASA) rectal 1000mg 1x daily at bedtime AND Mesalazine oral
2. Beclometasone oral 5mg 1x in morning

Maintain remission:

1. Thiopurines e.g. azathioprine
2. TNF-alpha inhbitors e.g. infliximab
3. Vedolizumab
4. Ciclosporin
5. Colectomy

Question 12

Complications of Ulcerative Colitis

Answer 12

Toxic megacolon
Colonic adenocarcinoma (3-5%)
Primary sclerosing Cholangitis 
Perforation
Infection 
Haemorrhage 
Inflammatory pseudopolyps
Uveitis, renal calculi, arthropathy, sacroiliitis, erythema nodosum etc.

Question 13

Prognosis for Ulcerative Colitis

Answer 13

Relapsing and remitting, normal life expectancy
Mortality increase in older people
Surgery may increase mortality
Most common cause of death is toxic megacolon

Poor prognostic factors: albumin, blood, CRP, dilated bowel loops, eight or more movements/day, fever