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AIP: Diarrhoea > Ulcerative colitis > Flashcards

Ulcerative colitis Flashcards

1
Q

What is ulcerative colitis?

A

chronic relapsing-remitting inflammatory granulomatous disease affecting the large bowel

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2
Q

What is the most common type of IBD?

A

ulcerative colitis

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3
Q

Which part of the bowel can be affected by ulcerative colitis?

A

most common site is the rectum as this is where inflammation starts

never spreads beyond ileocaecal valve - limited to colon

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4
Q

What is the nature of the location of bowel affected by ulcerative colitis?

A

most often at rectum, limited to colon but also continuous

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5
Q

At what ages are the peaks of incidence of ulcerative colitis?

A

15-25 years and 55-65 years

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6
Q

What are 7 features of the usual initial presentation of ulcerative colitis?

A
  1. Insidious and intermittent symptoms
  2. Bloody diarrhoea
  3. Urgency
  4. Tenesmus
  5. Abdominal pain, particularly left lower quadrant
  6. Systemic symptoms: weight loss, fever
  7. Extra-intestinal features
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7
Q

In what way do the features of ulcerative colitis develop with time?

A

insidious and intermittent

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8
Q

What is usually the location of abdominal pain in ulcerative colitis?

A

left lower quadrant

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9
Q

What are 4 extra-intestinal features of ulcerative colitis that are related to disease activity?

A
  1. Arthritis: pauciarticular, asymmetric
  2. Erythema nodosum
  3. Episcleritis (more common in CD)
  4. Osteoporosis
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10
Q

What are 5 extra-intestinal features of ulcerative colitis that are unrelated to disease activity?

A
  1. Arthritis: polyarticular, symmetric
  2. Uveitis (more common in UC than CD)
  3. Pyoderma gangrenosum
  4. Clubbing
  5. Primary sclerosing cholangitis (more common in UC than CD)
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11
Q

What is the difference between the arthritis in UC/CD that is related to vs unrelated to disease activity?

A
  • related: pauciarticular, asymmetric
  • unrelated: polyarticular, symmetric
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12
Q

What are 5 possible signs of UC on examination?

A
  1. Pallor secondary to anaemia (caused by PR bleeding)
  2. Clubbing
  3. Distension of abdomen
  4. Tenderness of abdomen on palpation
  5. PR may reveal tenderness and blood/mucus
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13
Q

Why can AA amyloidosis occur in UC?

A

secondary to chronic inflammation

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14
Q

What are 6 investigations for ulcerative colitis?

A
  1. Blood tests: FBC, ESR/CRP, LFTs
  2. Stool microscopy, culture and sensitivity, and C. difficile toxin
  3. Faecal calprotectin
  4. Colonoscopy + biopsy
  5. Barium enema + x-ray
  6. Acute setting: CT, AXR, CXR
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15
Q

What are 3 types of blood tests to perform in suspected UC?

A
  1. FBC: anaemia, raised WCC
  2. ESR/CRP
  3. LFTs: may show low albumin secondary to malabsorption
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16
Q

Why is faecal calprotectin a useful investigation?

A

can distinguish irritable bowel syndrome from IBD

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17
Q

What are 4 things which will be seen on colonoscopy in UC?

A
  1. Continuous inflammation
  2. Erythematous mucosa
  3. Loss of haustral markins
  4. Pseudopolyps
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18
Q

What are 3 things that will be seen on biopsy in UC?

A
  1. Loss of goblet cells
  2. Crypt abscess
  3. Inflammatory cells (predominantly lymphocytes)
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19
Q

What are 3 things which will be seen on barium enema +XR in UC?

A
  1. Lead-piping inflammation: secondary to loss of haustral markings
  2. Thumb-printing: markers of bowel wall inflammation
  3. Pseudopolyps: due to ulcerating mucosa adjacent to areas of regenerating mucosa
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20
Q

Why will lead-piping inflammation be seen on barium enema in UC?

A

secondary to loss of haustral markings

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21
Q

Why will thumb-printing be seen on barium enema in UC?

A

it’s a marker of bowel wall inflammation

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22
Q

Why will pseudopolyps be seen on barium enema in UC?

A

due to areas of ulcerating mucosa adjacent to areas of regenerating mucosa

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23
Q

In which scenario are colonoscopy and barium enema contraindicated and why?

A

in the acute setting due to the risk of bowel perforation

24
Q

What investigations should be performed instead of colonoscopy and barium enema in the acute setting for UC?

A

CT, abdominal x-ray and chest x-ray

can do limited flexible sigmoidoscopy rather than colonoscopy - reduced risk of perforation

25
Q

Why are abdominal and chest x-rays indicated in the acute setting of UC?

A

to exclude toxic megacolon and perforation

26
Q

Which criteria should be used in the case of an acute exacerbation of ulcerative colitis?

A

Truelove and Witt’s criteria for severity

27
Q

What are 6 criteria considered in the Truelove and Witt’s severity index for UC?

A
  1. Bowel movements - number /day
  2. Blood in stools
  3. Pyrexia (temperature greater than 37.8oC
  4. Pulse rate >90 bpm
  5. Anaemia (<100)
  6. ESR (mm/hour)
28
Q

What 3 categories does the Truelove and Witt’s severity index class UC into?

A
  1. Mild
  2. Moderate
  3. Severe
29
Q

What are the features of a mild UC exacerbation based on the 6 Truelove and Witt’s criteria?

A
  1. Bowel movements: <4 /day
  2. Blood in stools: no more than small amounts of blood
  3. Pyrexia: no
  4. Pulse rate >90: no
  5. Anaemia <100: no
  6. ESR: 30 or below
30
Q

What are the features of a moderate UC exacerbation based on the 6 Truelove and Witt’s criteria?

A

Bowel movements: 4-6 /day

Blood in stools: between mild and severe

Pyrexia: no

Pulse rate >90: no

Anaemia <100: no

ESR: 30 or below

31
Q

What are the features of a severe UC exacerbation based on the 6 Truelove and Witt’s criteria?

A
  • Bowel movements: 6 or more /day plus at least one of the features of systemic upset
  • Blood in stools: visible blood
  • Pyrexia: yes
  • Pulse rate >90: yes
  • Anaemia <100: yes
  • ESR: above 30
32
Q

What are 3 factors found to be linked to flares of UC?

A
  1. Stress
  2. Medications: NSAIDs, antibiotics
  3. Cessation of smoking
33
Q

Based on severity, when should patients with a flare of UC be admitted to hospital?

A

patients with a severe flare

34
Q

What are the 2 things that ulcerative colitis management can be split into?

A

inducing remission and maintaining remission

35
Q

What is the treatment for inducing remission from UC in mild-to-moderate proctitis? 3 steps

A
  • topical (rectal) aminosalicylate: for disal colitis, rectal mesalazine
  • if remision not achieved within 4 weeks, add an oral aminosalicylate
  • if remission still not achieved add topical or oral corticosteroid
36
Q

What is the treatment for inducing remission from UC in mild-to-moderate proctosigmoiditis and left sided UC? 3 steps

A
  • topical (rectal) aminosalicylate
  • if remission not achieved within 4 weeks, add high-dose oral aminosalicylate, or switch to high-dose oral aminosalicylate and topical corticosteroid
  • if remission still not achieved, stop topical treatments and offer an oral aminosalicylate and an oral corticosteroid
37
Q

What is the treatment for inducing remission from UC in mild-to-moderate extensive disease? 2 steps

A
  1. topical (rectal) aminosalicylate and a high-dose oral aminosalicylate
  2. if remission not achieved within 4 weeks, stop topical treatments and offer a high-dose oral aminosalicylate and an oral corticosteroid
38
Q

What is the management of severe colitis? 4 aspects

A
  1. admit and treat in hospital
  2. IV steroids usually given first-line
  3. IV ciclosporin may be used if steroids are contraindicated
  4. if after 24h no improvement, consider adding IV ciclosporin to IV corticosteroids or consider surgery
39
Q

If an oral aminosalicylate/ corticosteroid do not control proctitis/proctosigmoiditis what is another type of oral drug which can be tried?

A

oral tacrolimus

40
Q

If IV ciclosporin is contraindicated/ not tolerated for acute severe UC, what other drug can be considered?

A

infliximab

41
Q

What are 3 indications for emergency surgery for flares of UC?

A
  1. Acute fulminant ulcerative colitis
  2. Toxic megacolon with little improvement after 48-72h of IV steroids
  3. Symptoms worsening despite IV steroids
42
Q

What are 3 aspects of maintaining remission of US for proctitis and proctosigmoiditis, following a mild-to-moderate flare? 3 aspects

A

topical (rectal) aminosalicylate or oral aminosalicylate, or both

43
Q

What is the treatment for maintaining remission of US for left-sided and extensive UC following a mild-to-moderate flare?

A

low maintenance dose of oral aminosalicylate

44
Q

What is the treatment for maintaining remission of UC following a severe relapse, or 2 or more exacerbations in the past year?

A

oral azathioprine OR oral mercaptopurine

45
Q

What are the 2 indications for using oral azathioprine/mercaptoprine as maintenance of remission of UC?

A
  1. Severe relapse
  2. 2 or more exacerbations in the past year
46
Q

What is recommended about the use of methotrexate in UC?

A

not recommended for management of UC, unlike CD

47
Q

What are 2 surgical options for UC?

A
  1. Panproctocolectomy with permanent end ileostomy
  2. Colectomy with temporary end ileostomy
48
Q

When is the temporary end ileostomy reversed following colectomy for UC?

A

approximately 3 months later, by forming ileorectal anastomosis

49
Q

What is the alternative option to reversal of temporary endo ileostomy with ileorectal anastomosis?

A

completion proctectomy with permanent end ileostomy or ileal pouch anal anastomosis (IPAA)

50
Q

What are 2 short-term/ acute complications of UC?

A
  1. Toxic megacolon: severe form of colitis
  2. Massive lower GI haemorrhage
51
Q

In what proportion of UC patients is toxic megacolon seen?

A

15%

52
Q

What are 3 long-term complications of UC?

A
  1. Colorectal cancer
  2. Cholangiocarcinoma
  3. Strictures: can cause large bowel obstruction
53
Q

What affects the risk of developing colorectal cancer with UC?

A

higher risk with disease duration, severity and extent of colitis, concomitant primary sclerosing cholangitis

54
Q

What are 2 variable-term complications of UC?

A
  1. Primary sclerosing cholangitis
  2. Inflammatory pseodopolyps
55
Q

What is primary sclerosing cholangitis?

A

inflammation and fibrosis of extra- and intra-hepatic biliary tree

56
Q

What should be monitored in UC to check for presence of PSC?

A

LFTs, annually measures

57
Q

What are inflammatory pseudopolyps?

A

areas of normal mucosa between areas of ulceration and regeneration

AIP: Diarrhoea (8 decks)

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