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GI > Ulcerative Colitis > Flashcards

Ulcerative Colitis Flashcards

1
Q

What is it a subtype of?

A

Inflammatory bowel disease: ulcerative colitis + Crohn’s disease

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2
Q

What are inflammatory bowel diseases?

A

Chronic, relapsing, remitting inflammation of the gastrointestinal tract

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3
Q

What do the 2 types of IBD differ in?

A

Type and location of inflammation

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4
Q

When do the 2 types of IBD commonly present?

A

They are both lifelong conditions and commonly present in the teens and twenties (25% present in adolescence; median age at diagnosis is 29.5 years)

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5
Q

What, specifically, is ulcerative colitis?

A

A relapsing and remitting inflammatory disorder of the colonic mucosa (limited to colon/large bowel)

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6
Q

How does the inflammation progress in ulcerative colitis?

A

Continuous inflammation (only colon): begins at rectum and works proximally

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7
Q

What causes UC?

A

Inappropriate immune response against (?abnormal) colonic flora in genetically susceptible individuals

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8
Q

Is the appendix involved?

A

Appendix can be involved

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9
Q

Where might UC affect?

A

It may affect just the rectum = proctitis (30%)
Or extend to involve part of the colon = left-sided colitis (40%)
Or the entire colon = pancolitis (30%)

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10
Q

What is proctitis?

A

Inflammation confined to rectum

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11
Q

How does proctitis present?

A

Frequency, urgency, incontinence, tenesmus
Small volume mucus and blood
Proximal faecal stasis (constipation)

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12
Q

How is proctitis managed?

A

Reponds to topical therapy

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13
Q

What are the risk factors for UC?

A

Family history of the condition
HLA associations
3-fold as common in non-smokers (the opposite is true fro Crohn’s disease): symptoms may relapse on stopping smoking

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14
Q

What is the symptoms of UC?

A

BLOODY DIARRHOEA ± mucus
Abdominal pain (crampy)
Weight loss
Fatigue

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15
Q

What extra-intestinal signs may be seen in a patient with UC?

A

Clubbing
Primary sclerosing cholangitis
Sacroilitis

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16
Q

How is a diagnosis made?

A 
Bloods for markers of inflammation: normocytic anaemia, increased CRP/platelets, low albumin
Stool culture to rule out infection
Faecal Calprotectin 
	0-50ug/g stool = normal
	50-200 = equivocal
	>200 = elevated
Colonoscopy and colon mucosal biopsies
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17
Q

What is acute severe colitis?

A

Acute severe ulcerative colitis is a ‘life threatening medical emergency’ according to NCE 2015 (2% risk of mortality, <1% at specialist IBD centres)

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18
Q

What is the risk of emergency colectomy at admission in patients with ASC?

A

20-30%

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19
Q

What actually is acute severe ulcerative colitis?

A

Flare up/sudden worsening or first presentation of ulcerative colitis

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20
Q

What is the presentation of patients with ASC?

A

These patients look well, self caring and mobilising around ward (young with physiological reserve)
It is defined as 6 or more bloody stools/day AND any of:
- Temperature > 37.8 degrees celsius
- Tachycardia > 90 bpm
- Anaemia (Hb < 105 g/L)
- ESR > 30 mm/h, CRP > 30 mg/L

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21
Q

What are the investigations in patients with ASC?

A

3-4 serial stool cultures for C. difficile (ensure multiple stool MC&S/CDT to exclude infection)
AXR:
- Toxic dilatation
- Extent of disease: mucosal oedema, lead pipe (loss of haustra in the colon due to inflammation + swelling), proximal faecal loading)

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22
Q

What are the management options in patients with ASC?

A
  • 20-30% risk of emergency colectomy at admission
  • Stool chart
  • IV glucocorticoids
  • LMWH (prophylaxis) - 3x risk of (venous) thrombo-embolism
  • Avoid/stop non-steroidal analgesics, opiates, anti-diarrhoeals, anti-cholinergics + ask about OTC drugs
  • IV hydration, careful correction of electrolytes - low potassium or magnesium can precipitate toxic megacolon
23
Q

What are the complications that can arise in patients with ASC?

A

Toxic megacolon/ dilatation of colon (colonic diameter > 5.5cm):

  • Surgical emergency (colectomy)
  • Risk of sepsis/shock
  • Risk of perforation is high => serious infection and even death
24
Q

What percentage of patients will require a colectomy within 10 years diagnosis?

A

20-30%

25
Q

What are the management aims in patients with ulcerative colitis?

A

Goal is to induce/achieve then maintain disease remission

26
Q

In ulcerative colitis what is used in flares to induce remission?

A

Steroids/5-ASA

27
Q

Is 5-ASA used in Crohn’s disease?

A

5-ASA is not effective in Crohn’s disease

28
Q

What is 5-ASA used for in ulcerative colitis?

A

Remission induction (1st line therapy) or maintenance (1st line therapy)

29
Q

How does 5-ASA work?

A

Reduces inflammation

Topical to colonic mucosa (release mechanisms lead to colonic delivery)

30
Q

How is 5-ASA given?

A

PR for distal disease (superior to rectal steroids) or PO for more extensive disease (combine PO + PR if flare)

31
Q

What is the point in maintenance therapy?

A

Maintenance treatment reduces number + severity of relapses and reduces CRC risk

32
Q

How is moderate UC managed?

A

Induce remission with oral prednisolone (more powerful to reduce inflammation)
Then maintain on 5-ASA

33
Q

Why are steroids not used for maintenance?

A

Steroids have adverse side effects => not good for long term (maintenance) use

  • Weakened bones
  • Cataracts
  • Acne
  • Weight gain
  • Insomnia
  • Irritability
34
Q

What is the next step up treatment used for maintenance?

A

Immunomodulation: used for maintenance of UC + Crohn’s disease

35
Q

How does immunomodulation work?

A

Reduces activity of immune system

Maintains remission if your symptoms haven’t responded to other medicines

36
Q

How long does immunomodulation take to start working?

A

Usually take 2-3 months

37
Q

What are the problems with immunomodulation?

A

Significant side effects: abdominal pain, hepatotoxicity, pancreatitis and possible long term lymphoma risk and non-melanoma skin cancers
Can check TPMT to assess suitability

38
Q

What is the next step up maintenance treatment?

A

Biologics e.g. anti-TNF

39
Q

What are biologics used?

A

Used to treat patients intolerant of immune-modulation, or developing symptoms despite an immune-modulator

40
Q

What does the patient go through before being started on immunomodulation?

A

Patient is screened before being started on biologic therapy because it dampens down immune response and if they latent disease e.g. hep B/C, HIV, TB it will come to light
Always ensure patient has no contra-indications to treatment

41
Q

What is an alternative treatment more commonly used in children?

A

Exclusive elemental feeding can be as effective as steroids
Rests the GI tract
More commonly used in children: avoids slower growth risk that can happen with steroids
8 weeks
Usually nasogastric tube
Compliance difficult

42
Q

How should mild/moderate flare ups be treated?

A

At home

43
Q

Where should severe flare ups be managed?

A

In hospital to minimise risk of dehydration + potentially fatal complications such as the colon rupturing

44
Q

What does unwell + >6 motions/day mean?

A

Admit (acute severe colitis)

45
Q

What is ulcerative colitis surgery and when is it needed?

A

Colectomy
This is needed at some stage in around 20% of patients for failure of medical therapy or fulminant colitis with toxic dilatation/perforation

46
Q

What are the two pathways for surgery?

A

Emergency: acute severe colitis not responding to 72 hours high dose IV steroids ± anti-TNF biologic ‘rescue’ therapy
Elective: frequent relapses despite medical therapy (recurrent courses of steroids - should not have >2 courses per year), not able to tolerate medical therapy (unacceptable side effects affecting QOL), steroid dependant (relapse prior to or shortly after stopping steroids), patient choice

47
Q

What is the surgical procedure carried out for UC patients?

A

Total colectomy + rectal preservation + ileostomy (it is possible that a pouch procedure will be carried out at a later date)

48
Q

What happens after this procedure?

A

After total colectomy = end ileostomy (sits in right iliac fossa) + rectal stump (rectum normally calms down)
Subsequently: completion proctectomy (permanent stoma) vs. ileo-anal pouch (rectum is removed)

49
Q

What is the pouch procedure?

A

Ileum is made into a j-shaped pouch and connected to the top of the anal canal - the pouch collects waste and allows stool to pass through the anus in a normal bowel movement

50
Q

What are the pros and cons of the pouch procedure?

A

Pouches mean stoma reversal and the possibility of long-term continence but pouch opening frequency may still be around 6x/day and recurrent pouchitis can be troublesome (give antibiotics e.g. metronidazole + ciprofloxacin for 2wks)

51
Q

What are the complications associated with UC?

A

Acute (emergency):

  • Haemorrhage
  • Perforation
  • Toxic dilatation

Colonic cancer:

  • Risk related to disease extent and activity
  • Around 5-10% with pan colitis for 20 yrs
  • Surveillance colonoscopy
52
Q

What is Faecal Calprotectin?

A

Simple, non-invasive test for GI inflammation with high sensitivity, it is released into the GI tract in excess when there is any inflammation there (in general, the degree of elevation is associated with the extent of the inflammation)

53
Q

What is in the IBD differential diagnosis?

A

Chronic diarrhoea: malabsorption/malnutrition/IBS
Ileo-caecal TB (don’t see often, common in India)
Colitis must be distinguished from infective, amoebic and ischaemic colitis

GI (54 decks)

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