It’s funny how some patients just stick with you. I didn’t take a history from this guy, I might have put in his cannula or prepared his infusion- can’t remember exactly-, but whenever I come across ulcerative colitis, I always think of this 18 year old boy in the day unit receiving Infliximab with a song lyric tattoo and a cannula in his arm.
Definition: a relapsing and remitting inflammatory disorder of the colonic mucosa, which may affect just the rectum (proctitis, in 50%) or extend to involve part of the colon (left-sided colitis, in 30%) or the entire colon (pancolitis, in 20%). It does not spread proximal to the ileocaecal valve.
Aetiology/ risk factors:
-some genetic susceptibility
-positive family history of IBD in ~15%
-associated with increased serum pANCA and primary sclerosing colangitis.
Epidemiology: Prevalence = 100-200/100,000.
Incidence = 10-20/100,000/yr
-most present aged 15-30 years, uncommon before aged 10
-equal sex ratio up to age 40, then higher in males
-3x more common in non-smokers, symptoms may relapse on stopping smoking (Crohn’s more common in smokers)
-episodic or chronic diarrhoea +/- blood & mucus
–crampy abdominal discomfort
–bowel frequency relates to severity
–urgency/ tenesmus (feeling of incomplete defecation) ≈rectal UC
Systemic symptoms in attacks: fever, malaise, anorexia, weight loss
-may have no signs
–acute severe UC: fever, tachycardia + tender, distended abdomen
–PR examination- blood, mucus and tenderness
-signs of dehydration
-signs of iron deficiency anaemia
-apthous oral ulcers
-erythema nodosum- tender red subcutaneous nodules or lumps that are usually seen on both shins
-pyoderma gangrenosum- condition that causes tissue to become necrotic, causing deep leg ulcers
-conjunctivitis- inflammation of the conjunctiva (lining of the sclera and inner eyelid)
-episcleritis- inflammation of the episclera (thin layer between the conjunctiva and the sclera)
-iritis- inflammation of iris
-large joint arthritis, Add to dictionary, ankylosing spondylitis
–Primary Sclerosing Cholangitis, cholangiocarcinoma
Bloods: FBC (↓Hb ↑WCC), ↑ESR, ↑CRP, U&Es, LFTs (↓albumin), blood culture
Cross-match if severe blood loss.
Stool sample: MC+S (microscopy, culture and sensitivities)/CDT (C. difficile toxin)
–Faecal calprotection = marker of intestinal inflammation, used as marker for disease severity
Want to exclude infectious causes of diarrhoea (infectious colitis).
Infectious causes of bloody diarrhoea = CHESS
Entamoeba histolytica (parasite)
Abdominal x-ray– no faecal shadows, mucosal thickening/islands (pseudopolyps- when most of the mucosa has been lost, islands of mucosa remain giving it a pseudopolyp appearance.)
Thumb printing sign = thick haustral folds = thickened inflamed bowel wall
-colonic dilatation (toxic megacolon, > 6cm, bowel wall thickening and loss of mucosal folds in colon, occurs as complication of UC)
Toxic megacolon (colon is basically massive)
Erect chest x-ray- perforation as a complication = air under the diaphragm
Barium enema- never do during severe attacks or for diagnosis. Colonoscopy and barium enema carry a risk of perforation during acute attacks.
-mucosal ulceration with granular appearance and filling defects (pseudopolyps), featureless narrowed colon, loss of haustral pattern (loss of pouches that give segmented appearance along colon = leadpipe appearance).
Leadpipe appearance on Barium enema (narrowed bit of colon, no folds in wall)
Colonoscopy + Biopsy-colonoscopy shows disease extent and allows biopsy. Look for inflammatory infiltrate, goblet cell depletion, glandular distortion, mucosal ulcers, crypt abscesses.
-hyperaemic/ haemorrhagic granular colonic mucosa +/- pseudopolyps formed by inflammation. Punctate ulcers may extend deep into the lamina propria. Inflammation is normally not transmural (unlike Crohn’s).
To induce remission:
⇒5-ASA (5-aminosalicylic acid) e.g. sulfasalazine or mesalazine or olsalazine. These are the mainstay for both remission and maintenance in mild UC.
–steroids may help to induce remission e.g. oral prednisolone (20mg/d) +/- twice daily steroid foams PR (e.g. hydrocortisone), or prednisolone 20mg retention enemas.
Reduce steroid dose slowly if improving in 2 weeks, otherwise, treat as moderate UC.
Moderate UC-4-6 bowel motions/day, otherwise well:
–oral prednisolone (starting at 40mg/d and reducing dose over 6wks) + 5-ASA + twice daily steroid enemas.
-If improving, reduce steroids gradually but if no improvement after 2 weeks, treat as severe UC.
Severe UC-unwell & >6 motions/day:
-admit for nil by mouth (bowel rest) & IV hydration
-IV hydrocortisone 100mg/6h
–Rectal steroids e.g. hydrocortisone 100mg in 100ml 0.9% saline/12h PR
-Monitor temperature, pulse and BP, stool frequency/ character, FBC, ESR, CRP, U&Es, AXR.
-Consider blood transfusion e.g. if Hb <90-100g/L
–Parenteral nutrition required very rarely
-If improving in 5 days, transfer to oral prednisolone(40mg/24h) with a 5-ASA to maintain remission.
-If on day 3 CRP > 45 or > 6 stools/d = action needed, e.g. colectomy or rescue therapy with ciclosporin or infliximab (anti-TNF antibody), which can avoid urgent colectomy in steroid-refractory patients.
Topical therapies may be used
-proctitis (just rectum affected) may respond to suppositories, e.g. prednisolone or mesalazine.
-procto-sigmoiditis may respond to foams PR e.g. prednisolone or mesalazine.
-retention enemas may be needed in left-sided colitis
Suppositories-plug of medicine designed to melt at body temperature within the rectum
Foam enemas-medicine that is mixed into a foam that is sprayed into the rectum
Liquid enemas-medicine that is mixed into a liquid that is squeezed into the rectum
Surgery is needed at some stage in 20%.
-Indicated in perforation, massive haemorrhage, toxic dilatation and failed medical therapy.
e.g. proctocolectomy + terminal ileostomy (retain ileocaecal valve to reduce liquid loss)
Colectomy with ileo-anal pouch later
Immunomodulation agents may be used if there is no remission with steroids or if prolonged use of steroids is needed.
-e.g. azathioprine, methotrexate, infliximab, adalimumab, calcineurin inhibitors (ciclosporin, tacrolimus)
Maintenance is for life, with 5-ASAs. Sulfalazine (500mg/6h PO) is first line.
-toxic dilatation of colon (toxic megacolon- diameter > 6cm)
-colonic cancer ≈ 15% risk with pancolitis for 20 years
-gallstones and primary sclerosing colangitis
Extra GI manifestations as listed under signs.
–osteoporosis (from steroid treatment)
Prognosis: relapsing and remitting condition, with normal life expectancy