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Ulcerative Colitis

Title               

Ñ    Ulcerative Colitis            

Definition

Ñ    Chronic inflammatory disease

Ñ    Of unknown aetiology

That affects the:

Ñ    Colon and rectum

Pathogenesis

Causes

Ñ    Unknown

Ñ    More common in non-smokers than smokers

Ñ    Increased incidence in ex-smokers:

Ex-heavy smokers > ex-light smokers

Pathological Process

Ñ    Diffuse involvement, begins in the rectum and spreads proximally

Ñ    Goblet cell depletion

Ñ    Crypt abscesses

Ñ    Distorted crypts

Ñ    Lamina propria infiltrated with inflammatory cells

Clinical Features

History

Age

Ñ    Any age may be affected

Ñ    Peak 20-40 years

E&M

Ñ    Malaise

Ñ    Lassitude

Ñ    Tiredness

GIT

Ñ    Diarrhoea

Ñ    Blood and mucous per rectum

Ñ    Constipation:

Proctitis

Examination

E&M

Ñ    Weight loss:

Severe episode

IS

Ñ    Dry skin, decreased skin turgor:

Salt and water depletion

Severe episode

Ñ    Erythema nodosum

Ñ    Pyoderma gangrenosum

CVS

Ñ    Tachycardia:

Severe episode

GIT

Ñ    Aphthous ulcers

Ñ    Abdominal distension

Ñ    Tenderness over colon

HS

Ñ    Anaemia

CNS

Ñ    Episcleritis

Ñ    Uveitis

LMS

Ñ    Sacroiliitis

Ñ    Ankylosing spondylitis

Ñ    Peripheral arthropathy

Extraintestinal Manifestations of UC

Related to activity of colitis

Ñ    Aphthous ulcers

Ñ    Fatty liver

Ñ    Erythema nodosum

Ñ    Peripheral arthropathy

Usually related to activity of colitis

Ñ    Pyoderma gangrenosum

Ñ    Anterior uveitis

Unrelated to activity of colitis

Ñ    Sacroiliitis

Ñ    Ankylosing spondylitis

Ñ    Primary sclerosing cholangitis (PSC):

PSC may be complicated by:

·          Cholangiocarcinoma

Complications

Severe attack

Ñ    Stool frequency:

> 6 /day

Ñ    Fever:

 > 37.5° C

Ñ    Tachycardia:

> 90 /minute

Ñ    ESR:

> 30 mm in 1^st hour

Ñ    Anaemia:

Hb < 10 g/dL

Ñ    Albumin:

< 30 g/L

E&M

Ñ    Weight loss

GIT

Ñ    Haemorrhage

Ñ    Toxic dilatation (toxic megacolon)

Ñ    Perforation

Ñ    Dysplasia and malignancy

Ñ    Primary sclerosing cholangitis:

Cholangiocarcinoma

Investigations

Fluids

Blood

Haematology

Ñ    Anaemia

Ñ    ESR:

Elevated

Immunology

Ñ    PANCA:

May be positive

Biochemistry

Ñ    Decreased albumin:

Severe attack

Stools

Ñ    Culture to exclude infection

Imaging

Abdominal x-ray

Ñ    Dilated colon

Ñ    Thumb printing

Barium Enema

Ñ    Instant barium enema:

To show extent in acute severe disease

Nuclear Medicine

Labelled white cell scan:

Ñ    Determine extent

Ñ    Degree of activity

Endoscopy

Flexible sigmoidoscopy

Acute cases, unprepared (no bowel preparation):

Ñ    Diagnosis

Ñ    Activity

Colonoscopy

Ñ    To assess extent and activity:

Following treatment of acute attack

Ñ    Surveillance

Extent of disease

Ñ    Proctitis:

Rectum only

Ñ    Distal colitis:

Rectum and sigmoid

Ñ    Left sided colitis:

Distal to splenic flexure

Ñ    Extensive colitis:

Proximal to splenic flexure

Ñ    Total colitis:

Whole colon

Tissue Diagnosis

Histology

Ñ    Mucosal inflammation centred around the crypts with goblet cell depletion and cryptitis

Management

Control

Drugs

Induce remission

Ñ    5-ASA (amonosalicylic acid) preparations

Ñ    Steroids

Ñ    Ciclosporin may be used in resistant cases

Maintain remission

Ñ    5-ASA preparations

Ñ    Azathioprine, 6-mercaptopurine in resistant cases

Surgery

Ñ    Resistance to medical therapy

Ñ    Complications:

Haemorrhage, toxic megacolon, perforation, dysplasia, malignancy

Biological Agents

Ñ    Infliximab:

Severe disease

Prevention

Surveillance:

Ñ    Extensive disease  >10 years:

Requires colonoscopic surveillance

Prognosis

Ñ    80% have intermittent attacks

Ñ    Approximately 30% will require surgery

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