Ulcerative Colitis

Question 1

What two things are protective against ulcerative colitis?

Answer 1

1) Smoking

2) Appendicectomy

Question 2

What are risk factors for IBD?

Answer 2

• Enteric infections e.g. salmonella
• NSAIDs, isotretinoin, antibiotics
• Diet (simple sugars, urbanisation, microparticles, preservatives)

Question 3

What area is affected by UC?

Answer 3

Mucosa of the large colon from anal margin upwards

Question 4

What is the pathophysiology of UC?

Answer 4

• Exaggerated mucosal T cell response to host microbiota and/or external stimuli in contact of genetically receptive host
• Superficial inflammation linked to superficial symptoms (V&D)

Question 5

What are symptoms of UC?

Answer 5

• Rectal bleeding
• Diarrhoea
• Urgency
• No/minimal abdominal pain (maybe at end)
• No/minimal nutritional deficiency bc small bowel is unaffected

Question 6

When are the two periods of onset of UC (bimodal)?

Answer 6

20-30 and 50

Question 7

What tests are used to distinguish IBD from IBS?

Answer 7

1) Blood tests - raid CRP/ESR, anaemia, low albumin

2) Stool tests - raised faecal calprotectin

Question 8

What is the gold standard test for diagnosis of UC?

Answer 8

Endoscopy

Question 9

What does the endoscopy look like in UC?

Answer 9

• Superficial ulcers

- Whole mucosa looks abnormal, unlike Crohn’s where it is patchy

Question 10

What is proctitis UC?

Answer 10

Where the anus and rectum is involved

Question 11

What is left-sided colitis UC?

Answer 11

Where the anus, rectum, sigmoid and descending colon are involved

Question 12

What is pancolitis UC?

Answer 12

When the whole colon is affected

Question 13

How do you treat an acute exacerbation of UC to induce remission?

Answer 13

1) Steroids - prednisolone, IV hydrocortisone

2) Aminosalicylates (oral and rectal) - 5-ASA, mesalazine

Question 14

How do you treat UC to maintain remission?

Answer 14

1) Immunosuppressants e.g. azathioprine (thiopurines), methotrexate
2) Biologics e.g. adalimumab (anti-TNF), vedolizumab (anti-integrin)
3) Small molecules e.g. JAK inhibitors
4) Surgery (up to 20% over lifetime)

Question 15

Describe surgery for UC

Answer 15

• First remove colon and have to have stoma
• Form pouch
• Close stoma (but unlikely to have normal bowel function again)
• Often affects fertility

Question 16

What might an acute serious exacerbation of UC present with?

Answer 16

• 2 months of increased frequency, urgency and rectal bleeding
• Presents with 10 stools/day, rectal bleeding and abdominal pain
• Started steroids 3 days ago but no benefit
• Dehydration
• Abdominal tenderness

Question 17

What is a red flag in the context of UC?

Answer 17

Abdominal pain

Question 18

What would you do if a patient meets 2 or more Trulove and Witt criteria (assesses severity of colitis)?

Answer 18

Admit

Question 19

What should you think of when you see an acutely unwell patient with known UC?

Answer 19

Infection - might have been put on steroids when actually need abx

Question 20

What investigations would you do for someone presenting with acute UC?

Answer 20

• Blood test - FBC, U&Es, LFTs, CRP
• AXR (and CXR)
• Stool tests - MC&S, C diff
• Sigmoidoscopy - to exclude CMV superadded infection

Question 21

What scan should you do for everyone that comes in with acute UC?

Answer 21

AXR

Question 22

What is a serious complication that requires surgery that can be picked up on AXR?

Answer 22

Toxic megacolon/leadpipe colon - v dilated dark vowel, lots of air, contracts, will eventually rupture if not treated

Question 23

How would you manage someone with an acute UC exacerbation?

Answer 23

• IV hydrocortisone
• LMWH (even though bleeding, inflammation is pro-coagulant, easier to treat bleeding than clot)
• Daily blood tests and review

Question 24

What is rescue therapy for someone with acute UC exacerbation on day 3?

Answer 24

IV ciclosporin or infliximab

Question 25

What is the Travis criteria?

Answer 25

On day 3 of admission, if CRP > 45 or bowels open > 8 times a day, chance of colectomy on that admission is 85%

Question 26

How would you discharge a patient with acute UC exacerbation?

Answer 26

- Weaning course of prednisolone - Next infliximab infusion booked - Start azathioprine as outpatient - Sigmoidoscopy at week 14 to assess endoscopic response

Question 27

What are the key histological features of UC?

Answer 27

Crypt abscesses and mucosal inflammation

Question 28

What is key when treating acute UC?

Answer 28

1) IV steroids are key | 2) Day 3 assessment to decide on rescue therapy or surgery

Question 29

How do you optimise medical treatment in IBD?

Answer 29

With drug and antibody levels

Question 30

What is the M:F ratio for IBD?

Answer 30

1:1

Question 31

What type of disease is IBD?

Answer 31

Autoimmune

Question 32

What is the typical presentation of UC?

Answer 32

- Diarrhoea - Blood in stools - (Cramping, colicky abdominal pain) - Faecal urgency and frequency - Tenesmus (feeling of urgency to poop) - Weight loss

Question 33

How is IBD investigated?

Answer 33

- Faecal calprotectin via faecal sample - Stool culture and microscopy (infection) - Bloods - FBC, U&E, LFTs, ESR, CRP - Colonoscopy + ileal intubation + biopsy

Question 34

How is IBD managed?

Answer 34

- Topical medication - Oral medication - steroid, azathioprine/mercaptopurine/5-ASA - Surgical if failure of medical treatment - Surveillance - susceptible to cancer

Question 35

What are the surgical options for UC?

Answer 35

1) Emergency total colectomy with ileostomy (remove everything, anything left is cancer risk) 2) Colectomy with ileostomy and rectal preservation 3) Colectomy and ileorectal anastomosis (elective) - in terminal ileum faeces more fluid, would have to go to toilet many times a day but no stoma 4) Restorative proctocolectomy - ileoanal pouch (most popular) 5) Panproctocolectomy - permanent stoma, curative

Question 36

In what UC patients would you carry out surveillance for colorectal carcinoma after surgery?

Answer 36

In those whose symptoms started > 10 years ago and their rectum remains post surgery

Question 37

What is IBD?

Answer 37

Increase in pro-inflammatory cytokines which cause inflammation of the bowel mucosa