Ulcerative Collitis

Question 1

What area of the bowel does UC affect?

Answer 1

25% disease confined to rectosigmoid region
• ~50% disease extends to splenic flexure
• ~25% disease extends more proximally

Question 2

What are the symptoms of a mild/moderate flare of UC

Answer 2

• <4-6 BM/day w/ some rectal
bleeding
• Fecal urgency
• Left lower quadrant cramps
• Mild anemia &
hypoalbuminemia

Question 3

What are the symptoms of a severe UC flare

Answer 3

SEVERE DISEASE
• >6 bloody BM/day
• Severe anemia &
hypoalbuminemia
• Hypovolemic
• Impaired nutrition
• Abdominal pain & tenderness
• Fulminant colitis
• Rapidly worsening symptoms
• Signs of toxicity

Question 4

What does an endoscopy show in UC

Answer 4

Mild to moderate disease
• Erythema, friability & erosions
• Moderate to severe
• Deep ulcerations & spontaneous bleeding

Question 5

What ABD imaging is ordered in UC and what will it show

Answer 5

• Imaging
• Abdominal plain radiograph or CT scan
• Colonic dilation
• Other concomitant problems

Question 6

How is UC diagnosed

Answer 6

Colonoscopy
• Avoid if in fulminant disease
• Risk for perforation
• Determine extent of the disease
• Initial presentation of UC
• Indistinguishable from other causes of colitis
• Exclude other causes of colitis
• Infectious colitis
• Ischemic colitis
• Hx of radiation to pelvic region
• Laboratory
• Positive pANCA & negative ASCA

Question 7

What is the treatment plan for UC

Answer 7

• Mild to Moderate Colitis
• Mesalamine suppository1000 mg/day at HS or enema 4 G at HS 4-8 weeks
• Mesalamine 800 mg PO TID x6
• Refractory to mesalamine
• Add PO corticosteroid
Moderate to Severe Colitis
• Prednisone or Methylprednisolone
• 1st line agent for moderate/severe
disease
• Dosing dependent on illness severity
• Prednisone 40-60 mg/day
• Tapering of 5-10 mg/week
• Tapered to 20 mg/day
• 2.5 mg/week taper

Question 8

What biological agents can be used in UC

Answer 8

Biologic Agents
• Anti-TNF agents (i.e. Infliximab)
• 1st line after failure of conventional
therapy
• Anti-integrin therapy (i.e. Vedolizumab)
• Nonresponsive to anti-TNF agents
• Janus kinase inhibitors (i.e. Tofacitinib)
• Nonresponsive to anti-TNF
• Increase attraction to this as 1st line
agent
• Safety profile & PO dosing

Question 9

What is the treatment plan for fulminant colitis

Answer 9

• Toxic megacolon
• Colonic dilation >6 cm signs of toxicity
• Bowel rest
• Consider TPN
• Avoid opioids & anticholinergic agents
• Intravenous fluids
• Correct electrolytes
• Transfuse as needed
• CT scan
• Any significant dilation
• Serial abdominal plane film
• Ensure no worsening dilation or ischemia
• Stool work up
• Consider CMV superinfection
• Chemical VTE
• High risk for clots

Question 10

Adaptation of treatment plan in UC when symptoms improve vs don’t improve

Answer 10

Symptoms improved
• Clear liquid diet
• Transition to PO steroids
• Symptoms not improved
• No improvement in 3-5 days
• Consider anti-TNF therapy or cyclosporine
• Consult surgery

Question 11

Surgical consult and interventions with ulcerative colitis

Answer 11

Surgical Consultation
• Fulminant disease & toxic megacolon
• No improvement in 2-3 days
• Prevent perforation
• Broad spectrum ABX
• Cover for anaerobes & gram-negative bacteria
• Proctocolectomy w/ ileostomy
• Complete cure of disease