Ulcerative Colitis

Question 1

Who is commonly affected by ulcerative colitits (UC)?

Answer 1

It is most prevalent among the Caucasian population, with the presentation following a bimodal distribution between 15-25yrs for most cases and a smaller peak of incidence between 55-65yrs.

Question 2

Briefly describe the course of the disease

Answer 2

The disease typically follows a remitting and relapsing course. A severe fulminant exacerbation may be life-threatening, resulting in severe systemic upset, toxic megacolon, colonic perforation, and even death.

Question 3

What is shown in the image?

Answer 3

Histology of Bowel Segment in UC, showing non-granulomatous inflammation with crypt abscess (circled) formation.

Question 4

Briefly describe the pathophysiology of UC

Answer 4

Although the exact aetiology of ulcerative colitis is unknown, current theories suggest it develops as an interaction between genetic factors and environmental triggers.

It is characterised by diffuse continual mucosal inflammation of the large bowel, beginning in the rectum and spreading proximally, potentially affecting the entire large bowel. A portion of the distal ileum can become affected in a small proportion of cases, termed ‘backwash ileitis’ (if the ileocaecal valve is not competent).

Histological changes include inflammation of the mucosa and submucosa, crypt abscesses, and goblet cell hypoplasia. Repeated cycles of ulceration and healing may lead to raised areas of inflamed tissue termed ‘pseudopolyps’.

Question 5

What is the link between smoking and UC?

Answer 5

Smoking is protective against UC.

Question 6

Briefly differentiate between UC and Crohn’s

Note: site involvement, inflammation, macroscopic changes and microscopic changes

Answer 6

Question 7

What are the clinical features of UC?

Note: signs and symptoms

Answer 7

Ulcerative colitis is typically insidious in onset. The cardinal feature is bloody diarrhoea, with visible blood in stool reported in more than 90% of cases.

The most common manifestation of ulcerative colitis is proctitis, whereby the inflammation is confined to the rectum. Patients will complain of PR bleeding and mucus discharge, increased frequency, urgency of defecation, and tenesmus.

Patients presenting with more widespread colonic involvement are more likely to experience bloody diarrhoea with clinical features of dehydration and electrolyte imbalance. Systemic symptoms also include malaise, anorexia, and low-grade pyrexia.

Question 8

What are the clincial features of UC?

Note: on examination

Answer 8

Unless there is a severe exacerbation, clinical examination is generally unremarkable.

Fulminant colitis, toxic megacolon, or colonic perforation should be suspected if the patient complains of severe abdominal pain and on examination demonstrates systemic involvement or signs of peritonism.

Question 9

What is the name of the grading criteria for UC?

Answer 9

Truelove and Witt criteria.

Question 10

Describe mild UC according to Truelove and Witt Criteria

Note: bowel movements per day, blood in stool, pyrexia, pulse, anaemia and ESR

Answer 10

Question 11

Describe moderate UC according to Truelove and Witt Criteria

Note: bowel movements per day, blood in stool, pyrexia, pulse, anaemia and ESR

Answer 11

Question 12

Describe severe UC according to Truelove and Witt Criteria

Note: bowel movements per day, blood in stool, pyrexia, pulse, anaemia and ESR

Answer 12

Question 13

What other systems are affected by UC?

Answer 13

1. MSK
2. Skin
3. Eyes
4. Hepatobiliary

Question 14

What are the extra-intestinal MSK manifestations of UC?

Answer 14

Enteropathic arthritis (typically affecting sacroiliac and other large joints) or nail clubbing.

Question 15

What are the extra-intestinal skin manifestations of UC?

Answer 15

Erythema nodosum (tender red/purple subcutaneous nodules, typically found on the patient’s shins).

Question 16

What are the extra-intestinal eye manifestations of UC?

Answer 16

Episcleritis, anterior uveitis or iritis.

Question 17

What are the extra-intestinal hepatobiliary manifestations of UC?

Answer 17

Primary sclerosing cholangitis (chronic inflammation and fibrosis of the bile ducts).

Question 18

What is shown in image A and B?

Answer 18

Erythema nodosum.

Question 19

What investigations should be ordered for UC?

Note: laboratory

Answer 19

Routine bloods (FBC, U&Es, CRP, LFTs, and clotting) are required to examine for anaemia, low albumin (secondary to malabsorption), and evidence of inflammation (raised CRP and WCC).

In the UK, NICE guidelines recommend that faecal calprotectin testing is carried out in patents with recent onset lower gastrointestinal symptoms; it is raised in inflammatory bowel disease, but unchanged in irritable bowel syndrome. A stool sample should be sent for microscopy and culture.

Question 20

What investigations should be ordered for UC?

Note: imaging

Answer 20

The definitive diagnosis for ulcerative colitis is via colonoscopy with biopsy. Characteristic macroscopic findings are of continuous inflammation with possible ulcers and pseudopolyps visible. A flexible sigmoidoscopy may be sufficient and in clinical practice full colonoscopy is only required if the diagnosis is unclear; colonoscopy should be avoided in acute severe exacerbations.

In acute exacerbations, an abdominal radiograph (AXR) or CT imaging are used to assess for toxic megacolon and/or bowel perforation has occurred. AXR features of acute ulcerative colitis flares also include mural thickening and thumbprinting, indicating a severe inflammatory process in the bowel wall; in chronic cases of UC, a lead-pipe colon is often described- but this is usually best seen on barium studies.

Question 21

What is shown in image A?

Answer 21

(A) bowel fibrosis, secondary to chronic UC

Question 22

What is shown in image B?

Answer 22

(B) active inflammation in patient with UC.

Question 23

What is shown in image C?

Answer 23

(C) AXR changes in active UC, showing toxic megacolon with lead-pipe colon (seen in descending colon).

Question 24

Why should anti-motility drugs, such as loperamide, should be avoided in acute attacks?

Answer 24

Anti-motility drugs, such as loperamide, should be avoided in acute attacks, as these can precipitate toxic megacolon.

Question 25

Briefly describe the medical management of UC: _inducing remission_

Answer 25

Any acute attacks will also warrant **aggressive fluid resuscitation, nutritional support, and prophylactic heparin** (due to the prothrombotic state of IBD flares). The medical management to induce remission in UC requires use of **corticosteroid therapy** and **immunosuppresive agents**, such as mesalazine or azathioprine. **Biological agents**, such as infliximab, can be trialled as rescue therapy if then needed.

Question 26

Briefly describe the NICE guidelines for medical management and inducing remission in UC

Answer 26

NICE guidelines suggest that a stepwise approach is adopted, dependent upon the clinical severity and location of the exacerbation.

Question 27

Briefly describe the medical management of UC: _maintaining remission_

Answer 27

Once any acute event has been controlled, remission of the disease can be maintained using **immunomodulators**, such as mesalazine or sulfasalazine. **Infliximab or alternative monoclonal antibody therapy** can be used as next line therapies to maintain remission patients with recurrent symptoms. Due to increased risk of colorectal malignancy, **colonoscopic surveillance** is offered to people who have had the disease for \>10 years with \>1 segment of bowel affected (follow-up time frame depends on risk stratification of disease following initial endoscopy). Patients should be referred to **IBD-nurse specialists** and patient support groups. **Enteral nutritional support** should be considered in young patients with growth concerns, with close support from a nutritional team.

Question 28

How common is surgery in UC patients?

Answer 28

Approximately **30%** patients with ulcerative colitis will at some point require surgery.

Question 29

When is surgery indicated in UC patients?

Answer 29

Indications for acute surgical treatment include **disease refractory to medical management, toxic megacolon or bowel perforation**. Surgery may also be undertaken to reduce the risk of colonic carcinoma, if dysplastic cells are detected on routine monitoring.

Question 30

What surgery is curative for UC?

Answer 30

**Total proctocolectomy** is curative (with the patient requiring an **ileostomy**), yet many patients for disease control will often initially undergo a sub-total colectomy with preservation of the rectum (this can excised at a later stage if symptoms persist).

Question 31

What are the complications of UC?

Answer 31

* Toxic megacolon * Colorectal carcinoma * Osteoporosis * Requiring regular assessment for fracture risk and treated as necessary * Pouchitis

Question 32

What is toxic megacolon? How does it present? How is it treated?

Answer 32

The dilation of the colon in the absence of a mechanical obstruction. Present with severe abdominal pain, abdominal distension, pyrexia and systemic toxicity. Decompression of the bowel is required as soon as possible, due to high risk of perforation, and failure to respond to medical management is an indication for surgery.

Question 33

What is pouchitis? How does it present? How is it treated?

Answer 33

Inflammation of an ileal pouch. Typical symptoms include abdominal pain, bloody diarrhoea and nausea. Pouchitis should be treated with metronidazole and ciprofloxacin.

Question 34

What differentials should be considered for UC?

Answer 34

The primary differential diagnosis for ulcerative colitis is **Crohn’s disease**, as this can present in a similar fashion, however patients with UC patients typically experience a more bloody diarrhoea. Alternative forms of colitis include **chronic infections** (schistosomiasis, giardiasis and TB), **mesenteric ischaemia or radiation colitis**. Other differentials to consider include malignancy, IBS or coeliac disease.