Inflammatory bowel disease: Ulcerative colitis

Question 1

What is ulcerative colitis?

Answer 1

Ulcerative colitis (UC) is a form of inflammatory bowel disease.

Question 2

Where does inflammation start in ulcerative colitis?

Answer 2

Inflammation always starts at the rectum and is continuous.

Question 3

What is the peak incidence age for ulcerative colitis?

Answer 3

The peak incidence is in people aged 15-25 years and 55-65 years.

Question 4

What are common initial symptoms of ulcerative colitis?

Answer 4

Symptoms include bloody diarrhoea, urgency, tenesmus, and abdominal pain, particularly in the left lower quadrant.

Question 5

What is the preferred method for diagnosing severe colitis?

Answer 5

In severe colitis, flexible sigmoidoscopy is preferred over colonoscopy due to the risk of perforation.

Question 6

What are typical endoscopic findings in ulcerative colitis?

Answer 6

Typical findings include red, raw mucosa that bleeds easily, widespread ulceration with preservation of adjacent mucosa (‘pseudopolyps’), and inflammatory cell infiltrate in the lamina propria.

Question 7

What are the barium enema findings in long-standing ulcerative colitis?

Answer 7

Findings include loss of haustrations, superficial ulceration, ‘pseudopolyps’, and a narrow and short colon (‘drainpipe colon’).

Question 8

What are common extra-intestinal features of inflammatory bowel disease?

Answer 8

Common features include arthritis (pauciarticular, asymmetric), erythema nodosum, episcleritis, and osteoporosis.

Question 9

Which extra-intestinal feature is most common in both Crohn’s disease and ulcerative colitis?

Answer 9

Arthritis is the most common extra-intestinal feature in both CD and UC.

Question 10

What extra-intestinal features are unrelated to disease activity?

Answer 10

Unrelated features include polyarticular arthritis, uveitis, pyoderma gangrenosum, clubbing, and primary sclerosing cholangitis.

Question 11

What is the risk of colorectal cancer in patients with ulcerative colitis?

Answer 11

The risk is significantly higher than that of the general population, although studies report widely varying rates.

The increased risk is mainly related to chronic inflammation.

Question 12

What is the prognosis for patients with ulcerative colitis compared to those without?

Answer 12

Patients with ulcerative colitis have a worse prognosis than those without, partly due to delayed diagnosis.

Question 13

What are the factors that increase the risk of colorectal cancer in ulcerative colitis patients?

Answer 13

Factors include disease duration > 10 years, patients with pancolitis, onset before 15 years old, unremitting disease, and poor compliance to treatment.

Question 14

How should colonoscopy surveillance be determined in inflammatory bowel disease patients?

Answer 14

Colonoscopy surveillance should be decided following risk stratification.

Question 15

What is the follow-up colonoscopy schedule for lower risk patients?

Answer 15

Lower risk patients should have a 5 year follow-up colonoscopy if they have extensive colitis with no active endoscopic/histological inflammation, left sided colitis, or Crohn’s colitis of <50% colon.

Question 16

What is the follow-up colonoscopy schedule for intermediate risk patients?

Answer 16

Intermediate risk patients should have a 3 year colonoscopy if they have extensive colitis with mild active endoscopy/histological inflammation, post-inflammatory polyps, or a family history of colorectal cancer in a first degree relative aged 50 or over.

Question 17

What is the follow-up colonoscopy schedule for higher risk patients?

Answer 17

Higher risk patients should have a 1 year follow-up colonoscopy if they have extensive colitis with moderate/severe active endoscopic/histological inflammation, a stricture in the past 5 years, dysplasia in the past 5 years declining surgery, primary sclerosing cholangitis, transplant for primary sclerosing cholangitis, or a family history of colorectal cancer in first degree relatives aged <50 years.

Question 18

What are common factors linked to ulcerative colitis flares?

Answer 18

Stress, medications, NSAIDs, antibiotics, and cessation of smoking.

Question 19

How are flares of ulcerative colitis classified?

Answer 19

Flares are classified as mild, moderate, or severe.

Question 20

What characterizes a mild ulcerative colitis flare?

Answer 20

Fewer than four stools daily, with or without blood; no systemic disturbance; normal erythrocyte sedimentation rate and C-reactive protein values.

Question 21

What characterizes a moderate ulcerative colitis flare?

Answer 21

Four to six stools a day, with minimal systemic disturbance.

Question 22

What characterizes a severe ulcerative colitis flare?

Answer 22

More than six stools a day, containing blood; evidence of systemic disturbance such as fever, tachycardia, abdominal tenderness, distension or reduced bowel sounds, anaemia, and hypoalbuminaemia.

Question 23

What should be done for patients with evidence of severe ulcerative colitis?

Answer 23

Patients with evidence of severe disease should be admitted to hospital.

Question 24

What are the two main treatment phases for ulcerative colitis?

Answer 24

Treatment can be divided into inducing and maintaining remission.

Question 25

What classification is used for the severity of ulcerative colitis?

Answer 25

The severity of UC is classified as mild, moderate, or severe.

Question 26

What defines mild ulcerative colitis?

Answer 26

Mild: < 4 stools/day, only a small amount of blood.

Question 27

What defines moderate ulcerative colitis?

Answer 27

Moderate: 4-6 stools/day, varying amounts of blood, no systemic upset.

Question 28

What defines severe ulcerative colitis?

Answer 28

Severe: >6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers).

Question 29

What is the first-line treatment for mild-to-moderate proctitis?

Answer 29

Topical (rectal) aminosalicylate: rectal mesalazine is superior to rectal steroids and oral aminosalicylates.

Question 30

What should be done if remission is not achieved in mild-to-moderate proctitis within 4 weeks?

Answer 30

Add an oral aminosalicylate.

Question 31

What is the treatment for proctosigmoiditis and left-sided ulcerative colitis if remission is not achieved within 4 weeks?

Answer 31

Add a high-dose oral aminosalicylate OR switch to a high-dose oral aminosalicylate and a topical corticosteroid.

Question 32

What is the treatment for extensive disease if remission is not achieved within 4 weeks?

Answer 32

Stop topical treatments and offer a high-dose oral aminosalicylate and an oral corticosteroid.

Question 33

How should severe colitis be treated?

Answer 33

Severe colitis should be treated in hospital with IV steroids as first-line.

Question 34

What should be considered if there is no improvement after 72 hours of treatment for severe colitis?

Answer 34

Consider adding IV ciclosporin to IV corticosteroids or consider surgery.

Question 35

What is the maintenance treatment following a mild-to-moderate ulcerative colitis flare?

Answer 35

Topical (rectal) aminosalicylate alone or an oral aminosalicylate plus a topical (rectal) aminosalicylate.

Question 36

What is the maintenance treatment for left-sided and extensive ulcerative colitis?

Answer 36

Low maintenance dose of an oral aminosalicylate.

Question 37

What is recommended following a severe relapse or >=2 exacerbations in the past year?

Answer 37

Oral azathioprine or oral mercaptopurine.

Question 38

Is methotrexate recommended for the management of ulcerative colitis?

Answer 38

Methotrexate is not recommended for the management of UC.

Question 39

What evidence exists regarding probiotics in ulcerative colitis?

Answer 39

There is some evidence that probiotics may prevent relapse in patients with mild to moderate disease.