Ulcerøs kolitt - Amboss

Question 1

Hvordan er prevalensen av ulcerøs kolitt (UC)?

Amerikansk data

Answer 1

Question 2

Ved hvilket alderstrinn er insidensen av UC høyest?

Amerikansk data

Answer 2

20–25% of cases occur in individuals aged 20 years or younger, but ulcerative colitis rarely occurs in children younger than 10 years of age.

Question 3

Hvilke risikofaktorer for UC er identifisert?

Answer 3

In approximately 20% of cases, there is a family history of ulcerative colitis.

Question 4

Hvilke beskyttende faktorer for utvikling av UC er identifisert?

Answer 4

In the past, appendectomy was used to treat ulcerative colitis. Smoking decreases the risk of ulcerative colitis and has a positive effect on the course of the disease. The pathophysiology is not fully understood, as smoking has negative effects on other inflammatory diseases (e.g., Crohn disease). Smoking is inadvisable despite the positive effects it may have on ulcerative colitis.

Question 5

Hvordan klassifiserer man UC basert på utbredelsen av sykdommen?

Answer 5

The extent of disease is classified based on endoscopic findings.

Question 6

Hvilke klassifikasjoner baserer sykdomsforløpet ut fra alvorligheten av UC?

Answer 6

Truelove and Witts severity indez for ulcerative colitis

The Truelove and Witts severity index is calculated based on the frequency of bowel movements, amount of blood in stool, heart rate, temperature, and ESR. However, it does not include endoscopy findings or fecal inflammatory markers and is not a severity scale that can be used to track disease activity over time.

American College of Gastroenterology (ACG)

Classifies the severity of UC with a combination of both endoscopic findings and clinical presentation.

Others

Classifies UC based on:
- Response to mediction
- Disease course
- Patient´s QoL

Question 7

Hvordan klassifiserer ACG UC, og hvilke kriterier er tatt med?

Answer 7

The criteria are meant to be used as a guide to help physicians assess disease activity. Not all criteria need to be fulfilled.

Question 8

Hvordan klassifiserers UC basert på “Truelove and Witts” alvorlighetsindeks, og hvilke kriterier er med?

Answer 8

Clinical features that fall between the criteria for mild and severe disease are considered moderate severity.

Question 9

Hva er patofysiologien til UC?

Answer 9

A disruption of the intestinal mucosal barrier might be attributed to Th17 cell dysfunction, although the evidence for the involvement of Th17 cells is stronger in Crohn disease than in ulcerative colitis. Unlike ulcerative colitis, Crohn disease is characterized by transmural inflammation.

Question 10

Hvilke intestinale symptomer forekommer ved UC?

Answer 10

Tenesmus: A distressing and persistent but ineffectual urge to empty the rectum or bladder.

Question 11

Hvilke ekstraintestinale symptomer forekommer ved UC?

Answer 11

Question 12

Hva er vanlige forløp av UC?

Answer 12

Question 13

Hva er “backwash ileitis”?

Answer 13

Ulcerative colitis typically only affects the colon. Pathophysiology; However, as the term 'backwash' suggests, inflammation of the terminal ileum may be caused by the presence of feces due to a defective ileocecal valve.

Question 14

Hvordan møter man en pas. med mistenkt UC?

Answer 14

Hematochezia; The passage of bright red, fresh blood in or with stools. Most commonly caused by lower gastrointestinal bleeding (e.g., from diverticulosis, hemorrhoids, ulcerative colitis, or colorectal cancer). Can also be caused by severe upper GI bleeding. Disease severity is only in part based on endoscopic findings.

Question 15

Hvilke blodprøver tar man når man mistenker UC?

Answer 15

Blood tests are not routinely required for diagnosis but help assess disease activity and severity. There is no correlation between pANCA titer and disease activity. However, the presence of pANCA and the absence of anti-Saccharomyces cerevisiae antibodies in symptomatic patients is suggestive of ulcerative colitis.

Question 16

Hvilke avføringsprøver er indisert ved mistanke om UC?

Answer 16

Stool testing for causes of gastroenteritis is indicated in all patients. Fecal calprotectin and lactoferrin are noninvasive markers of mucosal inflammation and can help differentiate inflammatory and infectious bowel conditions from functional disorders. C. difficile infection (CDI) may be a differential diagnosis in patients with symptoms of ulcerative colitis; CDI may also be present in up to ∼ 50% of patients with ulcerative colitis. Concomitant infection is associated with adverse outcomes including hospitalization, surgery, and death.

Question 17

Hvilken metode er anbefalt for å diagnostisere og overvåke UC?

Answer 17

Ileocolonoscopy in patients with ASUC carries an increased risk of perforation. If ileocolonoscopy is not performed initially, it should be performed once symptoms improve.

Question 18

Hvilke endoskopiske funn ser man ved hhv.:
- Tidlig stadium
- Kronisk sykdom

Answer 18

Question 19

Når er det indikasjon for sigmoidoskopi ved UC?

Answer 19

Question 20

Når bruker man esophagogastroduodenoskopi (EGD)?

Answer 20

Not required for the diagnosis of ulcerative colitis in patients with a normal-appearing terminal ileum.

Question 21

Hva viser bildet?

Answer 21

Active ulcerative colitis; Endoscopic view of the colon. The mucosa appears edematous and several pseudopolyps are beginning to form. There is a loss of superficial vascular markings with a central area of spotty bleeding. These findings are characteristic of active ulcerative colitis.

Question 22

Hva viser bildet?

Answer 22

Active ulcerative colitis; Endoscopic view of the colon. The mucosa appears erythematous and edematous, indicating active inflammation. The vascular pattern has been lost and minor spontaneous hemorrhage is visible. A fibrin-covered ulceration (blue overlay) and several pseudopolyps (indicated by dashed lines) are visible. These features are characteristic of active ulcerative colitis.

Question 23

Hva viser bildet?

Answer 23

Acute ulcerative colitis; Colonoscopy photograph of the sigmoid colon. The mucosa is erythematous and edematous indicating active inflammation. There is a loss of superficial vascular markings, and several linear, semi-confluent ulcerations (green overlay) are present. These findings are characteristic of acute ulcerative colitis.

Question 24

Hva viser bildet?

Answer 24

Ulcerative colitis in remission; Endoscopic view of the colon in a patient with ulcerative colitis. The right side of the colon shows a loss of haustra and a diminished vascular pattern, both of which indicate previous exacerbations. On the left side of the colon, the haustral folds and vascular pattern are normal. There are no signs of active inflammation. This appearance is consistent with ulcerative colitis in remission.

Question 25

Hva viser bildet?

Answer 25

Pseudopolyps in ulcerative colitis; Colonoscopy. Multiple, smooth, sessile, shiny lesions (inflammatory pseudopolyps) can be seen as a result of mucosal regeneration and hyperplasia. These findings are characteristic of inflammatory pseudopolyps seen in chronic inflammatory conditions.

Question 26

Hva viser bildet?

Answer 26

Pseudopolyps in ulcerative colitis; Colonoscopy photograph. Multiple prominent, raised islands of normal mucosa can be seen as a result of mucosal regeneration and hyperplasia. These findings are characteristic of pseudopolyps seen in ulcerative colitis.

Question 27

Hva viser bildet?

Answer 27

Acute ulcerative colitis; Colonoscopy photograph. The mucosa is erythematous and edematous indicating active inflammation. Mucosal granularity, loss of superficial vascular markings, and ulcerations (exemplarily highlighted by green overlay) are also present. These findings are characteristic of acute ulcerative colitis.

Question 28

Hva viser bildet?

Answer 28

Active ulcerative colitis: Endoscopic view of the colon. The mucosa appears inflamed and shows several fibrin deposits (examples indicated by green overlay). The normal vascular pattern and haustral folds of the colon are no longer visible. These features are characteristic of active ulcerative colitis.

Question 29

Hva viser bildet?

Answer 29

Ulcerative colitis in remission; Endoscopic view of the colon in a patient with ulcerative colitis. The mucosa shows light, line-shaped scars with a loss of the normal vascular pattern indicating previous ulcerations (blue overlay). There are no signs of active inflammation. These findings are consistent with ulcerative colitis in remission.

Question 30

Hva viser bildet?

Answer 30

Ulcerative colitis in remission; Endoscopic view of the colon in a patient with ulcerative colitis. The colonic mucosa shows a reticulated pattern due to scarring. The typical vascular pattern and haustral folds are missing. There are no signs of active inflammation. These findings are consistent with ulcerative colitis in remission after a prolonged course of disease activity.

Question 31

Når, og hvilke bildemodaliteter bruker man ved UC?

Answer 31

Imaging studies are not routinely recommended for diagnosing ulcerative colitis but may be used as an adjunct to endoscopy, particularly for the detection of complications, or if endoscopy is not possible.

Rtg

CT eller MR abd.

Barium enema radiografi.

Abdominal UL

Question 32

Når er det indikasjon for å ta rtg. abd, og hvilke funn tyder på UC?

Answer 32

Findings suggestive of toxic megacolon on plain abdominal films also include mucosal islands and loss of haustrations. Abdominal x-ray is less sensitive than a CT scan for detecting perforation.

Question 33

Hva viser bildet?

Answer 33

Lead pipe sign; X-ray abdomen (AP view) of a patient with ulcerative colitis. A lack of haustral markings in the descending colon has resulted in a smooth cylindrical appearance (lead-pipe sign; green overlay). The lead-pipe sign has been described as a characteristic barium enema finding in longstanding ulcerative colitis. The sign is also visible on conventional radiography, CT, and MRI and has been observed in other inflammatory bowel diseases (e.g, Crohn disease, cathartic colon, tuberculosis).

Question 34

Hva viser bildet?

Answer 34

Pneumoperitoneum and Pneumoretroperitoneum; X-ray abdomen (AP erect view) and chest (PA and lateral views). Multiple air-fluid levels are seen in the colon and small bowel (examples indicated by black lines). Some dilated segments of left colon are seen and gas is present in the peritoneal space as a result of bowel perforation. Gas is primarily located beneath the diaphragms (green overlay) because of the erect positioning of the patient. Additional gas has dissected into the retroperitoneum (examples indicated by red overlay) and is visible as linear collections parallel to the spine.

Question 35

Når er det indikasjon for CT/MR ved UC, og hva er typiske funn?

Answer 35

E.g., due to stenosis or severe comorbidities.

Question 36

Når er det indikasjon for barium enema ved UC, og hva kan man finne?

Answer 36

The role of barium enema is limited, as it is less sensitive than other imaging modalities and is contraindicated in patients with obstruction or perforation.

Question 37

Når er det indisert å ta UL ved UC, og hva kan man finne?

Answer 37

Ultrasound can help identify inflammation but can not differentiate between ulcerative colitis and other types of inflammatory bowel disease.

Question 38

Hva viser bildet?

Answer 38

Ulcerative colitis; Transabdominal ultrasound of the descending colon. The four layers of the intestine remain distinguishable (despite thickening of the intestinal wall) in ulcerative colitis as only the mucosa and submucosa are affected. The intestinal lumen also appears hypoechoic due to acute inflammation. S: serosa; Mp: muscularis propria; Sm: submucosa; M: mucosa.

Question 39

Hva viser bildet?

Answer 39

Ulcerative colitis; Transabdominal ultrasound of the descending colon. The intestinal layers remain distinguishable (despite thickening of the intestinal wall) in ulcerative colitis as the mucosa and submucosa are affected. S: serosa; Mp: muscularis propria; Sm: submucosa; M: mucosa; Lr: luminal reflection.

Question 40

Hvilke histologiske funn forventer man ved tidlig stadiet av UC?

Answer 40

Question 41

Hvilke histologiske funn forventer man å finne ved kronisk stadiet av UC?

Answer 41

Question 42

Hva viser bildet?

Answer 42

Question 43

Hva viser bildet?

Answer 43

Question 44

Hva viser pilen til?

Answer 44

Question 45

Hva viser pilen til?

Answer 45

Question 46

Hva viser pilen til?

Answer 46

Question 47

Hva viser bildet?

Answer 47

Question 48

Hva viser bildet?

Answer 48

Question 49

Hvilke diff.diagnoser har man til UC?

Answer 49

Crohn disease.

Question 50

Hva viser bildet?

Answer 50

Ischemic colitis; Colonoscopy. A pale mucous membrane and a loss of vascular pattern can be seen. One large and multiple smaller fibrin-covered ulcerations are also visible (green overlay). These findings are consistent with ischemic colitis.

Question 51

Hva viser bildet?

Answer 51

Infectious colitis; Colonoscopy. A loss of vascular pattern and small pustules on the mucosa can be seen. The brown and yellow deposits are remaining bowel contents. These findings are consistent with infectious colitis.

Question 52

Hva er mikroskopisk kolitt?

Answer 52

Question 53

Hvilke histologiske subtyper av mikroskopisk kolitt?

Answer 53

Question 54

Hvordan er epidemiologien til mikroskopisk kolitt?

Answer 54

More common in collagenous colitis than in lymphocytic colitis.

Question 55

Hvilken etiologi har mikroskopisk kolitt?

Answer 55

Ukjent

Question 56

Hvilke risikofaktorer er identifisert i forb. med mikroskopisk kolitt?

Answer 56

Question 57

Hvilke symptomer opptrer sammen med mikroskopisk kolitt?

Answer 57

Question 58

Hvordan behandler man mikroskopisk kolitt?

Answer 58

Question 59

Hva viser bildet?

Answer 59

Lymphocytic colitis; Photomicrograph of a colon tissue sample (H&E stain; 200× magnification). Increased amounts of intraepithelial lymphocytes (examples indicated by green overlay) are dispersed between the enterocytes (example indicated by blue overlay), with > 20 lymphocytes per 100 enterocytes visible. There are no neutrophils nor is there architectural distortion, which would indicate infectious colitis or inflammatory bowel disease, respectively. Increased intraepithelial lymphocytes in the absence of neutrophils and architectural distortion is characteristic of lymphocytic colitis, a type of microscopic colitis.

Question 60

Hvordan går man fram når man skal behandle UC?

Answer 60

Medications can often be used at reduced doses during periods of remission.

Question 61

Hvordan behandler man akutt, alvorlig UC?

Answer 61

In patients with a concomitant CDI, vancomycin is preferred over metronidazole. Patients with frequent bowel movements and elevated CRP on day 3 of steroid therapy are highly likely to require a colectomy.

Question 62

Hvilken rolle har farmakologisk intervensjon ved UC, og hva er målet ved behandlingen?

Answer 62

Provide once-daily treatment options if available to improve patient adherence. I.e., restoration of normal bowel habits, no visible blood in stools, and no discomfort. I.e., resolution of mucosal inflammation, which can be assessed by endoscopy or fecal calprotectin if endoscopy is not possible.

Question 63

Hvilke medikamenter kan brukes for å indusere remisjon hos pas. med mild til moderat UC?

Answer 63

Defined as < 4–6 bowel movements per day, mild-to-moderate rectal bleeding, and no findings of systemic inflammation. First-line treatment: Patients with mild-to-moderate disease with risk factors for adverse events, e.g., high endoscopic severity scores, previous hospitalizations for colitis, steroid dependence, high CRP, and/or hypoalbuminemia, may benefit from more aggressive treatment. Suppositories are recommended for patients with proctitis; patients with proctosigmoiditis may derive more benefit from enemas. Some studies have shown benefit from less frequent, higher doses of mesalamine enemas (e.g., 4 g PR once daily at bedtime on weekends only) for maintenance of remission, which may be more convenient for patients. According to the 2020 AGA guideline, a higher dose (e.g., > 3 g PO once daily) may be considered in patients at the upper end of mild-to-moderate criteria and those who do not achieve remission with standard-dose mesalamine. The 2019 ACG guideline does not include a recommendation for high-dose mesalamine. Treatment with both a rectal and oral mesalamine is recommended over treatment with oral mesalamine alone for left-sided or extensive colitis. There is no evidence that the dose (between 1 g and 4 g) or formulation of mesalamine enema impacts treatment response. This recommendation is based on the 2020 AGA guideline. The 2019 ACG guideline does not include a recommendation for rectal corticosteroids. Despite the oral route of administration, budesonide MMX acts locally and causes limited off-target systemic effects.

Question 64

Hvordan induserer man remisjon hos pas. med moderat til alvorlig UC?

Answer 64

The combination of infliximab and azathioprine has been studied head-to-head against infliximab and azathioprine monotherapy alone in the UC SUCCESS trial. For this reason, the 2019 ACG guideline only recommends the combination of azathioprine and infliximab, whereas the 2020 AGA guideline has extrapolated the evidence and includes azathioprine in combination with other anti-TNF therapies and with vedolizumab. Especially if anti-TNF therapy is unsuccessful. Especially if anti-TNF treatment is unsuccessful.

Question 65

Hvordan induserer man remisjon hos pas. med akutt alvorlig UC?

Answer 65

There is no difference in efficacy between cyclosporine and infliximab; the choice should be driven by patient factors and provider experience.

Question 66

Hva gjelder ved bruken av kortikosteroider ved UC?

Answer 66

Systemic corticosteroids should only be used for induction of remission!

Steroid-sparing agents are preferred for maintenance of remission.

Question 67

Fyll ut oversikten over 5-ASA og 5-ASA derivatene

Answer 67

Rare cases: peripheral neuropathy, myocarditis, pericarditis, myelosuppression. Folic acid supplementation and monitoring of CBC and LFTs (liver function tests) are recommended.

Question 68

Hvilken tilleggsbehandling bør pas. med UC få?

Answer 68

There is no evidence that total bowel rest with parenteral nutrition reduces the need for surgery.

Question 69

Hvilken behandling kurerer UC, og hva er en av de største fordelen med denne typen behandling?

Answer 69

Operativ behandling!

Ulcerative colitis can be cured surgically. Surgical treatment also reduces the risk of colorectal cancer.

Question 70

Ved hvilke indikasjoner opererer man for UC?

Answer 70

Question 71

Hvilken type operasjon kan man bruke ved UC?

Answer 71

Question 72

Hvilke komplikasjoner kan oppstå etter operasjon av UC?

Answer 72

Pouchitis describes inflammation of the IPAA. It is thought that the inflammation may be caused by altered and/or increased bacterial flora, however, the exact etiology is unknown. Typical symptoms include increased stool frequency and urgency, abdominal cramps, and possibly incontinence. Management consists primarily of antibiotic treatment, although chronic or severe cases that are resistant to treatment may necessitate permanent diversion or excision of the pouch.

Question 73

Hvordan er langtidsbehandlingen av UC?

Answer 73

A cutoff of < 150 mg/kg of stool achieves adequate sensitivity and specificity to predict clinical and endoscopic remission; however, the optimum cutoff value for fecal calprotectin still needs to be determined. The specific time interval should be decided on an individual basis, taking into account the patient's combined risk factors.

Question 74

Hvilke komplikasjoner kan oppstå pga. UC?

Answer 74

The risk of developing colorectal cancer is particularly elevated in patients with longer disease duration (onset < 15 years of age), extensive disease, and concomitant PSC. In patients with extensive disease (pancolitis), the cancer risk is approx. 5–10% after 20 years and 12–20% after 30 years. Strictures occur in approximately 10% of cases of ulcerative colitis because of repeated inflammation. Because of the risk of cancer, strictures should be approached as malignant until proven otherwise.

Question 75

Hva bør man si til fertile kvinner om UC og graviditet?

Answer 75

Abdominal surgery (e.g., proctocolectomy, IPAA) can result in decreased fertility due to inflammation and consequent fibrosis of the fallopian tubes. Because of possible teratogenic effects, methotrexate should be discontinued at least 3 months before conception.

Question 76

Hvordan behandler man UC hos gravide kvinner?

Answer 76

Question 77

Hvordan er prognosen til pas. med UC?

Answer 77

On average, the life expectancy of patients with ulcerative colitis is normal.