Ulcerative colitis

Question 1

What is UC?

Answer 1

This is a type of IBD that characteristically involves the rectum and extends proximally to affect a variable length of the colon.
Recognised as a multifactorial polygenic disease, as the exact cause is still unknown,
Diffuse inflammation of the colonic mucosa and a relapsing, remitting course.

Question 2

Aetiology of UC

Answer 2

Occurs in genetically susceptible people in response to environmental triggers.
It is probably an autoimmune disease initiated by an inflammatory response to colonic bacteria.

Question 3

Pathophysiology of UC

Answer 3

Macroscopically, most cases arise in the rectum, with some patients developing terminal ileitis (i.e. extending up to 30cm) due to an incompetent ileocaecal valve or backwash ileitis.
Microscopically, UC usually involves only the mucosa, with the formation of crypt abscesses and a coexisting depletion of goblet cell.

Question 4

Classification of UC

Answer 4

UC is classified by severity:
S0: clinical remission (asymptomatic)
S1 (mild UC): the passage of ≤4 stools per day (with or without blood), absence of any systemic illness, and normal levels of inflammatory markers (erythrocyte sedimentation rate [ESR])
S2 (moderate UC): the passage of >4 stools per day but with minimal signs of systemic toxicity
S3 (severe UC): the passage of ≥6 bloody stools daily, pulse rate of at least 90 bpm, the temperature of at least 37.5°C (99.5°F), a haemoglobin level of <105g/L (10.5 g/dL), and ESR of at least 30 mm/hour.

Question 5

Signs & Symptoms of UC

Answer 5

Rectal bleeding 
Diarrhoea 
Blood in stool 
Abdominal pain 
Arthritis and spondylitis 
Malnutrition 
Abdominal tenderness 
Fever 
Weight loss 
Pallor 
Uveitis and episcleritis 
Skin rash

Question 6

Risk factors of UC

Answer 6

FHx of IBD 
HLA-B27
Infection
NSAIDs (cause a flare-up) 
Not smoking

Question 7

Investigations of UC

Answer 7

Stool studies (negative culture and C.dif toxins A &B, WBC present, elevated faecal calprotectin)
FBC (variable degree of anaemia)
Comprehensive metabolic panel (including LFTs)
ESR- >30 mm/hour suggests flare up
CRP- variable degree of elevation
Plain abdominal radiograph- dilated loops
Flexible sigmoidscopy/colonoscopy
Biopsies
Double-contrast barium enema

Question 8

Differentials of UC

Answer 8

Crohn's disease 
Indeterminate colitis 
Radiation colitis 
Infectious colitis
Diverticulitis 
IBS 
Mesenteric ischaemia/ ischaemic colitis 
Vasculitis
Prolonges use of cathortics

Question 9

Management of UC

Answer 9

This depends if there is an acute flare-up or for maintaining remission.

Question 10

Treatment of fulminant disease in UC

Answer 10

The fulminant disease is described as >10 stools, massive bleeding and severe system toxicity.
Treatment of this include:
-Admission + IV steroids (hydrocortisone or methylprednisolone)
-IV fluids
-Ciclosporin or infliximab (if the response to steroids isn’t great)

Question 11

What is infliximab?

Answer 11

Infliximab belongs to a group of medicines called ‘biological drugs.’
It is also referred to as an ‘anti-TNF drug’ because it works by targeting a protein in the body called TNF-alpha.
Your body naturally produces TNF-alpha as part of its immune response to help fight infections by temporarily causing inflammation in affected areas.
Over-production of this protein is thought to be partly responsible for the type of chronic (ongoing) inflammation found in Crohn’s and Colitis.
Infliximab binds to TNF-alpha, helping to prevent inflammation and relieve symptoms.

Infliximab is recommended as an option for the treatment of acute exacerbations of severely active ulcerative colitis only in patients in whom ciclosporin is contraindicated or clinically inappropriate.

Question 12

Treatment of severe non-fulminant disease

Answer 12

Topical + oral mesalazine (aminosalicylate)
Oral steroids (prednisolone)
If symptoms persist: Admission + IV steroids
Colectomy is the last line of treatment.

Question 13

Remission in proctitis (mild to moderate)

Answer 13

To induce remission in people with a mild-to-moderate first presentation or inflammatory exacerbation of proctitis, Offer a topical aminosalicylate as first-line treatment.
If remission is not achieved within 4 weeks, consider adding an oral aminosalicylate.
If further treatment is needed, consider adding a time-limited course of a topical or an oral corticosteroid.

Question 14

Remission in proctosigmoiditis and left-sided ulcerative colitis: mild to moderate

Answer 14

Offer a topical aminosalicylate as first-line treatment.
If remission is not achieved within 4 weeks, consider:
adding a high-dose oral aminosalicylate to the topical aminosalicylate or
switching to a high-dose oral aminosalicylate and a time-limited course of a topical corticosteroid.
If further treatment is needed, stop topical treatments and offer an oral aminosalicylate and a time-limited course of an oral corticosteroid.

Question 15

Remission in extensive ulcerative colitis: mild to moderate

Answer 15

Offer a topical aminosalicylate and a high-dose oral aminosalicylate as first-line treatment.
If remission is not achieved within 4 weeks, stop the topical aminosalicylate and offer a high-dose oral aminosalicylate with a time-limited course of an oral corticosteroid.
For people who cannot tolerate aminosalicylates, consider a time-limited course of an oral corticosteroid.

Question 16

Maintaining remission in proctitis and proctosigmoiditis

Answer 16

A topical aminosalicylate alone (daily or intermittent) Or
an oral aminosalicylate plus a topical aminosalicylate (daily or intermittent) Or
an oral aminosalicylate alone, explaining that this may not be as effective as a combined treatment or an intermittent topical aminosalicylate alone.

Question 17

Maintaining remission in left-sided and extensive colitis

Answer 17

Offer a low maintenance dose of an oral aminosalicylate

when deciding which oral aminosalicylate to use, take into account the person’s preferences, side effects and cost.

Question 18

Refractory disease in UC (all extent disease)

Answer 18

Consider oral azathioprine or oral mercaptopurine to maintain remission:
after 2 or more inflammatory exacerbations in 12 months that require treatment with systemic corticosteroids or
if remission is not maintained by aminosalicylates.
To maintain remission after a single episode of acute severe ulcerative colitis:
consider oral azathioprine or oral mercaptopurine
consider oral aminosalicylates if azathioprine and/or mercaptopurine are contraindicated or the person cannot tolerate them.

Question 19

Screening for colorectal cancer in people with IBD

Answer 19

Offer colonoscopic surveillance to people with inflammatory bowel disease whose symptoms started 10 years ago and who have:
ulcerative colitis (but not proctitis alone) or
Crohn’s colitis involving more than one segment of colon.

Question 20

Complications of UC

Answer 20

Colonic adenocarcinoma 
Benign stricture 
Toxic megacolon 
Perforation 
Infection 
Massive lower GI bleed 
Primary sclerosing cholangitis 
Inflammatory pseudopolyps
Dysplasia-associated lesion or mass (DALM)