Ulcerative Collitis Flashcards
List the suspected risk factors of Ulcerative Collitis.
Unknown.
Suggested hypotheses include:
•genetic susceptibility (chromosomes 12, 16),
•immune response to bacterial or self-antigens,
•environmental factors,
•altered neutrophil function,
•abnormality in epithelial cell integrity.
Positive family history of IBD (in about 15%).
Associated with ⬆️serum pANCA, primary sclerosing cholangitis.
Give a brief overview of the pathology of Ulcerative Collitis.
Ulcerative Collitis starts at the rectum and extends proximally.
Does not leave any normal patches of mucosa.
It can affect:
Colon and rectum - pancolitis
Left side of colon and rectum - distal colitis
Rectum alone - proctitis.
Mucosa is red and friable
There may be ulcers and pseudo polyps in severe disease.
Biopsy shows mucosal inflammation and goblet cell depletion but no granulomata.
Describe the epidemiology of Ulcerative Collitis.
•Prevalence
•Male:Female
Prevalence: 1/1500 (in developed world).
Higher prevalence in Ashkenazi Jews, Caucasians.
Uncommon before the age of 10 years, peak onset age 20–40 years.
Equal sex ratio up to age 40, then higher in males.
What would a patient with ulcerative Collitis complain of in their history?
Bloody or mucous diarrhoea (stool frequency related to severity of disease).
Tenesmus and urgency.
Crampy abdominal pain before passing stool, weight loss, fever.
Can be tachycardic or feverous
Symptoms of extra GI manifestations.
In moderate cases can be hypotensive, have signs of dehydration and some abdo tenderness.
In severe acute attacks rebound tenderness, suggesting peritonism, and abdo guarding occur.
Define Ulcerative Collitis.
Chronic relapsing and remitting inflammatory disease causing inflammation of the mucosa and submucosa of the large bowel only.
What would be found on examination of a patient with ulcerative Collitis?
- Signs of iron-deficiency anaemia
- dehydration
- Clubbing
- Abdominal tenderness
- tachycardia
•Blood, mucus and tenderness on PR examination.
Signs of extra GI manifestations.
What investigations would you perform on a patient with Ulcerative Collitis?
Bloods: •FBC (⬇️ Hb, ⬆️ WCC), •⬆️ ESR or CRP, •⬇️ albumin, •cross-match if severe blood loss, •LFT.
Stool:
•Culture as infectious colitis is a differential diagnosis.
•Faecal calprotectin – marker for disease severity.
AXR:
•To rule out toxic megacolon (see Toxic megacolon).
Flexible sigmoidoscopy or colonoscopy (and biopsy):
•Determines severity, histological confirmation, detection of dysplasia.
Barium enema:
•Mucosal ulceration with granular appearance and filling defects (pseudo-polyps),
•featureless narrowed colon,
•loss of haustral pattern (leadpipe or hosepipe appearance).
•Colonoscopy and barium enema may be dangerous in acute exacerbations (risk of perforation).
How would you manage a patient with Ulcerative Collitis?
Discuss:
•Markers of activity.
•Treatment of both mild and severe acute disease.
•Possible advice.
•Surgical options.
Markers of activity: •⬇️ Hb, •⬇️ alb, •⬆️ ESR or CRP •diarrhoea frequency —(>6 per day is severe), •bleeding, •fever.
Acute exacerbation:
•IV rehydration,
•IV corticosteroids,
•antibiotics,
•bowel rest,
•parenteral feeding may be necessary, and
•DVT prophylaxis.
•Monitor fluid balance and vital signs closely.
•If toxic megacolon develops, low threshold for proctocolectomy and ileostomy as perforation has a mortality of 30%.
Mild disease:
•Oral or rectal 5-aminosalicylic acid derivatives,
—e.g. sulphasalazine and/or rectal steroids.
Moderate to severe disease:
•Oral steroids and oral 5-ASA.
•Immunosuppression with azathioprine, cyclosporine, 6-mercaptopurine, infliximab (anti-TNF monoclonal antibody).
Advice:
Patient education and support.
Treatment of complications.
Regular colonoscopic surveillance.
Surgical:
Indicated for failure of medical treatment, presence of complications or prevention of colonic carcinoma.
Proctocolectomy with ileostomy or an ileo-anal pouch formation.
What complications could you expect as a result of Ulcerative Collitis?
Gastrointestinal: •Haemorrhage, •toxic megacolon, •perforation, •colonic carcinoma (in those with extensive disease for >10 years), •gallstones •PSC.
Extra-gastrointestinal manifestations (10–20%): •Uveitis, •renal calculi, •arthropathy, •sacroiliitis, •ankylosing spondylitis, •erythema nodosum, •pyoderma gangrenosum, •osteo-porosis (from steroid treatment), •amyloidosis.
What is the prognosis for patients with Ulcerative Collitis?
A relapsing and remitting condition, with normal life expectancy.
Poor prognostic factors (ABCDEF):
Albumin (38°C in first 24 h).
What factors would indicate a severe acute episode of Ulcerative Collitis?
•electrolyte imbalance •dehydration •⬆️ ESR or CRP •diarrhoea frequency —(>6 per day is severe), •fever.
