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A - MSRA Gastrointestinal [7] > [44] Ulcerative Colitis > Flashcards

[44] Ulcerative Colitis Flashcards

1
Q

What is ulcerative colitis?

A

A relapsing and remitting inflammatory disorder of the colonic mucosa

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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

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3
Q

What is the exception to UC never spreading past the ileocaecal valve?

A

Backwash ileitis

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4
Q

Which ethnic group is UC most prevalent among?

A

Caucasian

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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

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6
Q

Which gender is most commonly affected by UC?

A

Equal

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7
Q

What course does UC typically follow?

A

Relaxing and remitting course

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8
Q

When might UC be life-threatening?

A

In a severe fulminant exacerbations

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9
Q

What can a severe fulminant exacerbation of UC cause?

A
  • Severe systemic upset
  • Toxic megacolon
  • Colonic perforation
  • Death
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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

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11
Q

How far can punctuate ulcers extend in UC?

A

May extend deep into the lamina propria

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12
Q

Is inflammation transmural in UC?

A

Not normally

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13
Q

What is UC characterised by?

A

Diffuse continual mucosal inflammation of the large bowel, beginning in the rectum and spreading proximally

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14
Q

What histological changes may be seen in UC?

A
  • Inflammation of mucosa and submucosa
  • Crypt abscesses
  • Goblet cell hypoplasia
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15
Q

What can repeated cycles of ulceration and healing in UC lead to?

A

Raised areas of inflamed tissue termed ‘pseudopolyps’

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16
Q

How is UC differentiated from Crohn’s disease?

A

By continuous inflammation which is limited to the mucosa

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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

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18
Q

What effect does smoking have on the risk of UC?

A

It is protective against UC

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19
Q

What is a strong risk factor for UC?

A

Family history

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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
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21
Q

What % of cases of UC have blood in the stools?

A

90%

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22
Q

When might systemic features be present in UC?

A

In attacks

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23
Q

What systemic features may be present in UC attacks?

A
  • Fever
  • Malaise
  • Anorexia
  • Weight loss
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24
Q

What is the most common manifestation of UC?

A

Proctitis

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25
Q

What is proctitis?

A

Inflammation of the rectum

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26
Q

What are the symptoms of proctitis?

A
  • PR bleeding and mucus discharge
  • Increased frequency
  • Urgency of defecation
  • Tenesmus
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27
Q

What symptoms are patients with more widespread colonic involvement of UC more likely to experience?

A
  • Bloody diarrhoea
  • Clinical features of dehydration and electrolyte imbalance
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28
Q

What are the examination signs of UC?

A

May be none

In acute severe UC, might see tachycardia, fever, and a tender, distended abdomen

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29
Q

How many motions a day is considered to be mild UC?

A

4 or less

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30
Q

How many motions a day is considered to be moderate UC?

A

5

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31
Q

How many motions a day is considered to be severe UC?

A

6 or more

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32
Q

How much rectal bleeding is there in mild UC?

A

Small amount

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33
Q

How much rectal bleeding is there in moderate UC?

A

Moderate amount

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34
Q

How much rectal bleeding is there in severe UC?

A

Large amount

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35
Q

What is the resting pulse rate in mild UC?

A

<70bpm

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36
Q

What is the resting pulse rate in moderate UC?

A

70-90bpm

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37
Q

What is the resting pulse rate in severe UC?

A

<90

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38
Q

What is the temperature in mild UC?

A

Apyrexical

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39
Q

What is the temperature in moderate UC?

A

37.1 - 37.8

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40
Q

What is the temperature in severe UC?

A

>37.8

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41
Q

What are the haemoglobin levels in mild UC?

A

>100g/L

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42
Q

What are the haemoglobin levels in moderate UC?

A

105-100g/L

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43
Q

What are the haemoglobin levels in severe UC>

A

<105g/L

44
Q

What is the ESR level in mild UC?

A

<30

45
Q

What is the ESR level in severe UC?

A

>30

46
Q

How is UC investigated?

A
  • Bloods
  • Colonoscopy and biopsy
  • Stool MC&S
  • Faecal calprotectin
  • AXR
47
Q

What bloods are done in UC?

A
  • FBC
  • ESR
  • CRP
  • U&E
  • LFTs
  • Blood cultures
48
Q

How is the definitive diagnosis of UC made?

A

Via colonoscopy with biopsy

49
Q

What are the characteristic macroscopic findings on colonoscopy in UC?

A

Continuous inflammation with possible ulcers and pseudopolyps

50
Q

Describe the use of flexible sigmoidoscopy in the investigation of UC

A

A flexible sigmoidoscopy may be sufficient, and in clinical practice full colonoscopy is only required if the diagnosis is unclear

51
Q

When should colonoscopy be avoided in UC?

A

Acute severe exacerbations

52
Q

Why is stool MC&S done in suspected UC?

A

To rule out infectious causes

53
Q

What infectious causes can be ruled out using MC&S in suspected UC?

A
  • Campylobacter
  • C. difficile
  • Salmonella
  • Shigella
  • E. Coli
  • Amoebae
54
Q

Why is an AXR required in an acute exacerbation of UC?

A

To determine if toxic megacolon and/or bowel perforation have occured

55
Q

What are the AXR features of acute UC?

A
  • Mural thickening and thumb printing
  • Lead-pipe colon in chronic cases
56
Q

What treatment will any acute attacks of UC warrant?

A
  • Aggressive fluid resuscitation
  • Nutritional suppport
  • Prophylactic heparin
57
Q

Why is prophylactic heparin required in acute attacks of UC?

A

Due to the promthrombotic state of IBD flares

58
Q

What approach does NICE guidelines recommend in an acute attack of UC?

A

A stepwise approach dependant on clinical severity and location of exacerbation

59
Q

What is step 1 in the management of mild to moderate UC with proctitis?

A

Topical mesalazine or sulfasalazine

60
Q

How is topical mesalazine or sulfasalazine administered?

A

Suppositories or enema, taking into account persons preferences

61
Q

What can be given if the person declines or cannot tolerate aminosalicylates in step 1 treatment of mild to moderate UC with proctitis?

A

Topical corticosteroids are second line

62
Q

What is step 2 in the management of mild to moderate UC with proctitis?

A

Addition of oral prednisolone to aminosalicylate therapy to induce remission

63
Q

When is step 2 treatment started in mild to moderate UC?

A

If there is no improvement after 4 weeks of step 1 therapy, or if symptoms worsen despite treatment

64
Q

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?

A

Adding oral tacrolimus

65
Q

What is step 1 management of mild to moderate UC with left-sided or extensive inflammation?

A

High induction dose mesalazine or sulfasalazine

66
Q

What is second line in step 1 treatment of mild to moderate UC with left sided or extensive inflammation?

A

Oral prednisolone

67
Q

What is step 2 mangement of mild to moderate UC with left-sided or extensive inflammation?

A

Same as step 2 management for mild to moderate UC with proctitis

68
Q

What is step 1 in the management of severe UC?

A

IV corticosteroids, and consider need for surgery

69
Q

What medication is second line in the step 1 management of severe UC?

A

IV ciclosporin

70
Q

What is step 2 management for severe UC?

A

Consider adding IV ciclosporin to intravenous corticosteroids

71
Q

When should you consider surgery in step 2 management of severe UC?

A
  • Little or no improvement within 72 hours of starting IV corticosteroids
  • Symptoms worsen at any time, despite corticosteroid treatment
72
Q

How can remission be maintained in UC once any acute event has been controlled?

A

Using immunomodulators, such as mesalazine or sulfasalazine

73
Q

What is second line to aminosalicylates in the maintenance of remission in UC?

A

Infliximab, or an alternative monoclonal antibodies

74
Q

What should UC patients be referred to?

A
  • An IBD nurse specialist
  • Patient support groups
75
Q

When should enternal nutritional support be considered in UC?

A

In young patients with growth concerns

76
Q

What should enteral nutrition in UC be provided with close support from?

A

A nutritional team

77
Q

When is colonoscopic surveillance offered in UC?

A

In people who have had the disease for >10 years with >1 segment of the bowel affected

78
Q

Why is colonoscopic surveillance offered in UC?

A

Due to the increased risk of colorectal malignancy

79
Q

What does the colonoscopic follow-up time frame depend on in UC?

A

The risk stratification of the disease following initial endoscopy

80
Q

What % of those with UC will at some point require surgery?

A

30%

81
Q

What are the indications for acute surgical treatment in UC?

A
  • Disease refractory to medical management
  • Toxic megacolon
  • Bowel perforation
82
Q

When might surgery be undertaken to reduce the risk of colonic carcinoma in UC?

A

If dysplastic cells are detected on routine monitoring

83
Q

What surgery is curative in UC?

A

Total proctocolectomy

84
Q

What is the problem with a total proctocolectomy?

A

The patient requires an ileostomy

85
Q

How can the requirement for an ileostomy be avoided in surgical UC patients?

A
  • Ileal pouch-anal anastomosis operation
  • Sub-total colectomy with preservation of rectum
86
Q

What happens in an ileal pough-anal anastomosis operation?

A

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
Q

What can be done if symptoms persist following a sub-total colectomy?

A

The rectum can be exised at a later state

88
Q

What are the complications of UC?

A
  • Toxic megacolon
  • Colorectal carcinoma
  • Osteoporosis
  • Pouchitis
89
Q

When can a patient have the complication of pouchitis?

A

If they have an ileal pouch following an ileal pouch-anal anastomosis operation

90
Q

What is toxic megacolon?

A

A serious complication of UC, characterised by dilation of the colon to at least 6cm diameter on AXR

91
Q

How do patients with toxic megacolon typically present?

A
  • Severe abdominal pain
  • Abdominal distention
  • Pyrexia
  • Systemic toxicity
92
Q

How is toxic megacolon managed?

A

Urgent decompression of the bowel

93
Q

Why is decompression of the bowel required as soon as possible in toxic megacolon?

A

Due to the risk of perforation

94
Q

What is failure to respond to medical management an indication for in toxic megacolon?

A

Surgery

95
Q

What is the risk of colon cancer in UC related to?

A

Disease extent and activity

96
Q

What is the risk of colon cancer in those who have had pancolitis for 20 years?

A

5-10%

97
Q

How are colonic cancer precursor lesions spotted in UC?

A

Surveillance colonoscopy is performed every 1-5 years

98
Q

On what basis are biopsies taken during surveillance colonoscopy in UC?

A

Either random biopsies, or biopsies guided by differential uptake by abnormal mucosa of dye sprayed endoscopically

99
Q

What is pouchitis?

A

Inflmmation of an ileal pouch

100
Q

What are the typical symptoms of pouchitis?

A
  • Abdominal pain
  • Bloody diarrhoea
  • Nausea
101
Q

How should pouchitis be treated?

A

Metronidazole and ciprofloxacin

102
Q

What are the musculoskeletal manifestations of UC?

A

Enteropathic arthritis

103
Q

What joints does enteropathic arthritis typically affect?

A

Sacroiliac and other large joints

104
Q

What are the skin manifestations of UC?

A

Erythema nodosum

105
Q

What are the manifestations of UC in the eyes?

A
  • Episcleritis
  • Anterior uveitis
  • Iritis
106
Q

What are the hepatobiliary manifestations of UC?

A

Primary sclerosing cholangitis

107
Q

What is primary sclerosing cholangitis?

A

Chronic inflammation and fibrosis of bile ducts

A - MSRA Gastrointestinal [7] (44 decks)

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