Ulcerative Colitis

Question 1

What is UC?

Answer 1

• Chronic inflammatory disease resulting in relapsing and remitting IBD of colonic mucosa

Question 2

What are the types of UC?

Answer 2

• ulcerative proctitis
• left-sided colitis
• pancolitis

Question 3

What are the features of UC that is different to Crohns?

*remember CLOSE UP

Answer 3

• Continuous inflammation
• Limited to colon and rectum
• Only superficial mucosa affected
• Smoking is protective
• Excrete blood and mucus
• Use aminosalicylates
• Primary Sclerosing Cholangitis

Question 4

What is the Px of UC?

Answer 4

• Inappropriate immune response to colonic flora in genetically susceptible people

Question 5

What age group does UC present in?

Answer 5

15-25 and 55-65

Question 6

What is unhealthy but a protective factor for UC?

Answer 6

Smoking

Question 7

What are the Sx for UC?

Answer 7

• GI related
  
  • +/- bloody/mucus stool
  • crampy abdominal discomfort
  • tenesmus
• Systemic
  
  • fatigue
  • weight loss
  • iron def. anaemia

Question 8

What are the extraintestinal manifestations of UC?

Answer 8

• clubbing
• eythema nodosum
• conjunctivitis
• uveitis
• iritis
• large joint arthritis
• Ankylosing spondylitis

Question 9

What Ix would you order for UC?

Answer 9

Bedside

• Observations
• ECG
• Urinalysis
• Stool culture - exclude infective colitia
• Faecal calprotectin (marker of intestinal inflammation)

Bloods

• Full blood count
• Liver function tests
• Urea & electrolytes
• CRP
• Arterial/venous blood gas
• Haematinics
• Magnesium
• Clotting
• Autoantibodies (e.g. p-ANCA)

Imaging

• AXR- if suspicious of toxic megacolon and assess proximal constipation

Special Test

• Flex sigmoidoscopy- safer choice
• Colonoscopy- look for proximal disease

Question 10

What is calprotectin?

Answer 10

Protein released by intestines when inflammed

Question 11

What criteria is used to assess severity of UC?

Answer 11

Truelove and Witts

Question 12

What are the parameters measured in Truelove and Witts?

Answer 12

• Bowel motions
• rectal bleeding
• temperature
• resting pulse
• haemoglobin
• ESR

Question 13

What are the Cx of UC?

*think acute and chronic

Answer 13

Acute

• toxic dilation of colon >6cm
• venous thromboembolism

Chronic

• colonic cancer

Question 14

What are the Tx for UC to induce remission?

Answer 14

• If admittted to hospital - VTE prophylaxis (Heparin)
• Mild to moderate
  
  • First line: meselazine (aminosalicylate) per rectal
  • If remission is not achieved within 4 weeks, add an oral aminosalicylate
  • if remission still not achieved add topical or oral corticosteroid
• Severe
  
  • First line: IV corticosteroid
  • IV ciclosporin if corticosteroid contraindicated
  • IV steroid + IV ciclosporin - second lie
  • Surgery

Question 15

What medications are used to maintain remission?

Answer 15

1. Thiopurines (Azathioprine, mercaptopurine)

• Check TPMT enzyme before use
• SE: Bone marrow suppresion, pancreatitis, hepatoxicity

2. Biologics (infliximab, adalimumab)

Question 16

What is the surgical option for UC?

Answer 16

• Panproctocolectomy + ileo-anal anastomosis (J pouch)

Question 17

How is UC severity classified?

Answer 17

• mild: < 4 stools/day, only a small amount of blood
• moderate: 4-6 stools/day, varying amounts of blood, no systemic upset
• severe: >6 bloody stools per day + features of systemic upset
  
  • Temperature greater than 37.8°C

Heart rate greater than 90 beats per minute

Anaemia (Hb less than 105g/ L)

Erythrocyte sedimentation rate greater than 30 mm/hour

Question 18

What are the macroscopic features of UC?

Answer 18

• red inflammed mucosa
• continous inflammation
• friable
• inflammatory polyps

Question 19

What are the microscopic features of UC?

Answer 19

• Goblet cell depletion
• Crypt abcess
• Inflammatory infiltrate in lamina propia

Question 20

What are pt admitted to hospital with acute IBD at risk of?

Answer 20

• VTE
• Need prophylactic heparin