Ulcerative Colitis

Question 1

Peak age incidence for UC

Answer 1

15-40yrs old
Incidence in people >60 is increasing though

Question 2

Pathophysiology of UC

Answer 2

• Environmental exposures
• Genetic predisposition
• Dysregulated immune response
• Dysbiosis - altered gut microbiota

Question 3

Histological changes UC

Answer 3

• Non-granulomatous inflammation - submucosa and mucosa
• Crypt abscesses
• Goblet cell hypoplasia
• Can get pseudopolyps from repeated cycles of ulceration and healing - raised areas

Question 4

Smoking UC

Answer 4

Protective role - unlike in Crohns

Question 5

Symptoms of UC

Answer 5

• Most common - proctitis
• Inflammation confined to rectum
• Bloody diarrhoea
• Others inc mucus discharge PR, increased stool freq and urgency, tenesmus

Question 6

If widespread colonic involvement, what are some additional symptoms?

Answer 6

• Dehydration
• Systemic symptoms eg malaise, anorexia, low grade pyrexia

Question 7

Disease grading for UC

Answer 7

• Truelove and Witt criteria
• Based on bowel movements, blood in stool, pyrexia, pulse, anaemia, ESR

Question 8

Extra-intestinal manifestations of UC

Answer 8

SAME AS CROHNS - recall list of MSK, skin, eyes, hepatobiliary
But no renal

Question 9

Investigations UC - bloods and bedside

Answer 9

• Same as Crohns
• Bloods- FBC, LFT (albumin), CRP
• Faecal calprotectin
• Stool MC&S

Question 10

Imaging for UC

Answer 10

• Colonoscopy with biopsy = most sensitive and specific tool for diagnosis
• Acute flare - urgent CT - check for obstruction, toxic megacolon or perforation

Question 11

Endoscopic findings of mild and then moderate/severe UC

Answer 11

• Clear demarcation where inflammation ends
• Erythema
• Vascular congestion

If more severe:
* Loss of vascular patterns
* Mucosal friability
* Ulcers
* Pseudopolyps

Question 12

Scoring system for extent and severity of UC

Answer 12

• Extent - Montreal score
• Severity - Mayo score

Question 13

AXR signs of acute flare UC

Answer 13

• Mural thickening
• Thumb printing sign (wall oedema)
• Lead pipe colon if severe, chronic case - muscularis mucosae hypertrophy

Question 14

General management UC

Answer 14

• Same as Crohns
• Refer to gastro
• IBD MDT input
• IBD nurse specialists
• Consider enteral nutrition and low fibre diets

Question 15

Surveillance for UC

Answer 15

• Same as Crohns
• Endoscopic surveillance for colorectal cancer
• If had disease more than 10 years and more than 1 segment of bowel affected

Question 16

Medical management - mild to moderate UC

Answer 16

• Mesalazine for inducing remission and maintanance
• Can be suppository for proctitis or orally if left sided/extensive colitis
• If not responding to mesalazine, try corticosteroids

Question 17

Moderate to severe disease UC management

Answer 17

• Corticosteroids
• If improve, biologics eg anti TNF (infliximab) or vedolizumab or thiopurines (azathiopruine) can be used for maintenance

Question 18

Management of acute flare of UC

Answer 18

• Admission usually
• IV corticosteroids
• If these fail - ciclosporin or inflximab therapy - surgery if not improved after 4-7 days
• Fluids
• Prophylactic heparin + antiembolic stockings - prothrombotic state

Question 19

Surgical management UC indications

Answer 19

• Emergency - toxic megacolon, colonic perforation uncontrolled bleeding
• Elective - medically refractory disease, medication intolerance, colorectal cancer (or endoscopically irresectable dysplasia)

Question 20

Emergency surgery often done for UC

Answer 20

• Segmental or subtotal colectomy with stoma formation
• Subtotal is whole colon gone but leave rectum and anus
• Segmental is portion of colon removed

Question 21

Elective operation choice often

Answer 21

• Proctocolectomy and ileal pouch anal anastomosis - esp if keen to avoid stoma
• Often done staged approach - 3 stages, allows recovery between procedures and reduces patient morbidity
• Other option is proctocolectomy with end ileostomy

Question 22

3 stages of proctocolectomy and ileal-pouch anal anastomosis

Answer 22

1. Subtotal colectomy with end ileostomy
2. Completion proctectomy and ileal-pouch anal anastomosis formation with temporary loop ileostomy
3. Ileostomy reversal

Question 23

Complications of UC

Answer 23

• Toxic megacolon
• Colorectal adenocarcinoma
• Pouchitis - inflammation if ileal pouch if undergone an IPAA

Question 24

Presentation and management toxic megacolon

Answer 24

• Abdominal pain, distension, pyrexia and systemic upset
• Decompression of bowel - high risk of perforation, failure to respond to medical therapy = indication for surgery (NBM and NG tube)

Question 25

Presentation and management pouchitis

Answer 25

* Bloody diarrhoea and abdominal pain * Metronidazole and ciprofloxacin