Ulcerative Colitis

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.


Ulcerative colitis

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:

-cause unknown

-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)

Symptoms:

-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

Signs:

-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

Extra-intestinal signs:

clubbing

Image result for nail clubbing

-apthous oral ulcers

Image result for aphthous ulcers

-erythema nodosum- tender red subcutaneous nodules or lumps that are usually seen on both shins

Image result for erythema nodosum

-pyoderma gangrenosum- condition that causes tissue to become necrotic, causing deep leg ulcers

Image result for pyoderma gangrenosum

-conjunctivitis- inflammation of the conjunctiva (lining of the sclera and inner eyelid)

Image result for conjunctivitis

-episcleritis- inflammation of the episclera (thin layer between the conjunctiva and the sclera)

Image result for episcleritis

-iritis- inflammation of iris

Image result for iritis

-large joint arthritis, Add to dictionary, ankylosing spondylitis

-fatty liver

Primary Sclerosing Cholangitis, cholangiocarcinoma

-nutritional deficits

-amyloidosis

Investigations:

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

Campylobacter

Haemorrhagic E.coli

Entamoeba histolytica (parasite)

Salmonella

Shigella

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.)

Image result for axr ulcerative colitis

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)

Image result for toxic megacolon ulcerative colitis

Toxic megacolon (colon is basically massive)

Erect chest x-ray- perforation as a complication = air under the diaphragm

Image result for erect cxr bowel perforation

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).

Image result for ulcerative colitis lead pipe barium enema

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.

Image result for ulcerative colitis biopsy

-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).

Management:

To induce remission:

Mild UC

⇒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

Topical preparations:

Suppositories-plug of medicine designed to melt at body temperature within the rectum

Picture 61

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

mesalamine.png

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)

Related image

Colectomy with ileo-anal pouch later

Image result for proctocolectomy ileoanal pouch

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)

Maintaining remission-

Maintenance is for life, with 5-ASAs. Sulfalazine (500mg/6h PO) is first line.

Complications:

-perforation

-bleeding, haemorrhage

-toxic dilatation of colon (toxic megacolon- diameter > 6cm)

-venous thrombosis

-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)

-renal calculi

Prognosis: relapsing and remitting condition, with normal life expectancy

References: Cheese & Onion, Rapid Medicine
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