[44] Ulcerative Colitis Flashcards
(107 cards)
1
Q
What is ulcerative colitis?
A
A relapsing and remitting inflammatory disorder of the colonic mucosa
2
Q
What part of the bowel does UC affect?
A
May affect just the rectum, or extend to involve part of the colon, or the entire colon. It never spreads proximal to the ileocaecal valve
3
Q
What is the exception to UC never spreading past the ileocaecal valve?
A
Backwash ileitis
4
Q
Which ethnic group is UC most prevalent among?
A
Caucasian
5
Q
What age is UC most common?
A
It follows a bimodal distribution between 15-25 years for most cases, with a smaller peak of incidence between 55-65 years
6
Q
Which gender is most commonly affected by UC?
A
Equal
7
Q
What course does UC typically follow?
A
Relaxing and remitting course
8
Q
When might UC be life-threatening?
A
In a severe fulminant exacerbations
9
Q
What can a severe fulminant exacerbation of UC cause?
A
- Severe systemic upset
- Toxic megacolon
- Colonic perforation
- Death
10
Q
What is the pathophysiology of UC?
A
An inappropriate immune response against colonic flora in genetically susceptible individuals in hyperaemic and haemorrhagic colonic mucosa, with or without pseudopolyps formed from inflammation
11
Q
How far can punctuate ulcers extend in UC?
A
May extend deep into the lamina propria
12
Q
Is inflammation transmural in UC?
A
Not normally
13
Q
What is UC characterised by?
A
Diffuse continual mucosal inflammation of the large bowel, beginning in the rectum and spreading proximally
14
Q
What histological changes may be seen in UC?
A
- Inflammation of mucosa and submucosa
- Crypt abscesses
- Goblet cell hypoplasia
15
Q
What can repeated cycles of ulceration and healing in UC lead to?
A
Raised areas of inflamed tissue termed ‘pseudopolyps’
16
Q
How is UC differentiated from Crohn’s disease?
A
By continuous inflammation which is limited to the mucosa
17
Q
What is the aetiology of UC?
A
The exact aetiology is unknown, but current theories suggest it develops as an interaction between genetic factors and environmental triggers
18
Q
What effect does smoking have on the risk of UC?
A
It is protective against UC
19
Q
What is a strong risk factor for UC?
A
Family history
20
Q
What are the symptoms of UC?
A
- Episodic or chrnoic diarrhoea, with or without blood or mucus
- Crampy abdominal discomfort
- Increased bowel frequency
- Urgency
21
Q
What % of cases of UC have blood in the stools?
A
90%
22
Q
When might systemic features be present in UC?
A
In attacks
23
Q
What systemic features may be present in UC attacks?
A
- Fever
- Malaise
- Anorexia
- Weight loss
24
Q
What is the most common manifestation of UC?
A
Proctitis
25
What is proctitis?
Inflammation of the rectum
26
What are the symptoms of proctitis?
* PR bleeding and mucus discharge
* Increased frequency
* Urgency of defecation
* Tenesmus
27
What symptoms are patients with more widespread colonic involvement of UC more likely to experience?
* Bloody diarrhoea
* Clinical features of dehydration and electrolyte imbalance
28
What are the examination signs of UC?
May be none
In acute severe UC, might see tachycardia, fever, and a tender, distended abdomen
29
How many motions a day is considered to be mild UC?
4 or less
30
How many motions a day is considered to be moderate UC?
5
31
How many motions a day is considered to be severe UC?
6 or more
32
How much rectal bleeding is there in mild UC?
Small amount
33
How much rectal bleeding is there in moderate UC?
Moderate amount
34
How much rectal bleeding is there in severe UC?
Large amount
35
What is the resting pulse rate in mild UC?
\<70bpm
36
What is the resting pulse rate in moderate UC?
70-90bpm
37
What is the resting pulse rate in severe UC?
\<90
38
What is the temperature in mild UC?
Apyrexical
39
What is the temperature in moderate UC?
37.1 - 37.8
40
What is the temperature in severe UC?
\>37.8
41
What are the haemoglobin levels in mild UC?
\>100g/L
42
What are the haemoglobin levels in moderate UC?
105-100g/L
43
What are the haemoglobin levels in severe UC\>
\<105g/L
44
What is the ESR level in mild UC?
\<30
45
What is the ESR level in severe UC?
\>30
46
How is UC investigated?
* Bloods
* Colonoscopy and biopsy
* Stool MC&S
* Faecal calprotectin
* AXR
47
What bloods are done in UC?
* FBC
* ESR
* CRP
* U&E
* LFTs
* Blood cultures
48
How is the definitive diagnosis of UC made?
Via colonoscopy with biopsy
49
What are the characteristic macroscopic findings on colonoscopy in UC?
Continuous inflammation with possible ulcers and pseudopolyps
50
Describe the use of flexible sigmoidoscopy in the investigation of UC
A flexible sigmoidoscopy may be sufficient, and in clinical practice full colonoscopy is only required if the diagnosis is unclear
51
When should colonoscopy be avoided in UC?
Acute severe exacerbations
52
Why is stool MC&S done in suspected UC?
To rule out infectious causes
53
What infectious causes can be ruled out using MC&S in suspected UC?
* Campylobacter
* C. difficile
* Salmonella
* Shigella
* E. Coli
* Amoebae
54
Why is an AXR required in an acute exacerbation of UC?
To determine if toxic megacolon and/or bowel perforation have occured
55
What are the AXR features of acute UC?
* Mural thickening and thumb printing
* Lead-pipe colon in chronic cases
56
What treatment will any acute attacks of UC warrant?
* Aggressive fluid resuscitation
* Nutritional suppport
* Prophylactic heparin
57
Why is prophylactic heparin required in acute attacks of UC?
Due to the promthrombotic state of IBD flares
58
What approach does NICE guidelines recommend in an acute attack of UC?
A stepwise approach dependant on clinical severity and location of exacerbation
59
What is step 1 in the management of mild to moderate UC with proctitis?
Topical mesalazine or sulfasalazine
60
How is topical mesalazine or sulfasalazine administered?
Suppositories or enema, *taking into account persons preferences*
61
What can be given if the person declines or cannot tolerate aminosalicylates in step 1 treatment of mild to moderate UC with proctitis?
Topical corticosteroids are second line
62
What is step 2 in the management of mild to moderate UC with proctitis?
Addition of oral prednisolone to aminosalicylate therapy to induce remission
63
When is step 2 treatment started in mild to moderate UC?
If there is no improvement after 4 weeks of step 1 therapy, or if symptoms worsen despite treatment
64
What should be considered if there is inadequate response to oral prednisolone after 2-4 weeks of step 2 therapy for mild to moderate UC with proctitis?
Adding oral tacrolimus
65
What is step 1 management of mild to moderate UC with left-sided or extensive inflammation?
High induction dose mesalazine or sulfasalazine
66
What is second line in step 1 treatment of mild to moderate UC with left sided or extensive inflammation?
Oral prednisolone
67
What is step 2 mangement of mild to moderate UC with left-sided or extensive inflammation?
Same as step 2 management for mild to moderate UC with proctitis
68
What is step 1 in the management of severe UC?
IV corticosteroids, and consider need for surgery
69
What medication is second line in the step 1 management of severe UC?
IV ciclosporin
70
What is step 2 management for severe UC?
Consider adding IV ciclosporin to intravenous corticosteroids
71
When should you consider surgery in step 2 management of severe UC?
* Little or no improvement within 72 hours of starting IV corticosteroids
* Symptoms worsen at any time, despite corticosteroid treatment
72
How can remission be maintained in UC once any acute event has been controlled?
Using immunomodulators, such as mesalazine or sulfasalazine
73
What is second line to aminosalicylates in the maintenance of remission in UC?
Infliximab, or an alternative monoclonal antibodies
74
What should UC patients be referred to?
* An IBD nurse specialist
* Patient support groups
75
When should enternal nutritional support be considered in UC?
In young patients with growth concerns
76
What should enteral nutrition in UC be provided with close support from?
A nutritional team
77
When is colonoscopic surveillance offered in UC?
In people who have had the disease for \>10 years with \>1 segment of the bowel affected
78
Why is colonoscopic surveillance offered in UC?
Due to the increased risk of colorectal malignancy
79
What does the colonoscopic follow-up time frame depend on in UC?
The risk stratification of the disease following initial endoscopy
80
What % of those with UC will at some point require surgery?
30%
81
What are the indications for acute surgical treatment in UC?
* Disease refractory to medical management
* Toxic megacolon
* Bowel perforation
82
When might surgery be undertaken to reduce the risk of colonic carcinoma in UC?
If dysplastic cells are detected on routine monitoring
83
What surgery is curative in UC?
Total proctocolectomy
84
What is the problem with a total proctocolectomy?
The patient requires an ileostomy
85
How can the requirement for an ileostomy be avoided in surgical UC patients?
* Ileal pouch-anal anastomosis operation
* Sub-total colectomy with preservation of rectum
86
What happens in an ileal pough-anal anastomosis operation?
A pouch is formed from the loops of ileum, which acts as a reservoir for intestinal contents, which is then anastomosed to the anus, aiming to achieve faecal continence
87
What can be done if symptoms persist following a sub-total colectomy?
The rectum can be exised at a later state
88
What are the complications of UC?
* Toxic megacolon
* Colorectal carcinoma
* Osteoporosis
* Pouchitis
89
When can a patient have the complication of pouchitis?
If they have an ileal pouch following an ileal pouch-anal anastomosis operation
90
What is toxic megacolon?
A serious complication of UC, characterised by dilation of the colon to at least 6cm diameter on AXR
91
How do patients with toxic megacolon typically present?
* Severe abdominal pain
* Abdominal distention
* Pyrexia
* Systemic toxicity
92
How is toxic megacolon managed?
Urgent decompression of the bowel
93
Why is decompression of the bowel required as soon as possible in toxic megacolon?
Due to the risk of perforation
94
What is failure to respond to medical management an indication for in toxic megacolon?
Surgery
95
What is the risk of colon cancer in UC related to?
Disease extent and activity
96
What is the risk of colon cancer in those who have had pancolitis for 20 years?
5-10%
97
How are colonic cancer precursor lesions spotted in UC?
Surveillance colonoscopy is performed every 1-5 years
98
On what basis are biopsies taken during surveillance colonoscopy in UC?
Either random biopsies, or biopsies guided by differential uptake by abnormal mucosa of dye sprayed endoscopically
99
What is pouchitis?
Inflmmation of an ileal pouch
100
What are the typical symptoms of pouchitis?
* Abdominal pain
* Bloody diarrhoea
* Nausea
101
How should pouchitis be treated?
Metronidazole and ciprofloxacin
102
What are the musculoskeletal manifestations of UC?
Enteropathic arthritis
103
What joints does enteropathic arthritis typically affect?
Sacroiliac and other large joints
104
What are the skin manifestations of UC?
Erythema nodosum
105
What are the manifestations of UC in the eyes?
* Episcleritis
* Anterior uveitis
* Iritis
106
What are the hepatobiliary manifestations of UC?
Primary sclerosing cholangitis
107
What is primary sclerosing cholangitis?
Chronic inflammation and fibrosis of bile ducts
