Ulcerative Colitis

UC

Presentation

Most common:

  • Bloody diarrhoea
  • Rectal bleeding
  • Diarrhoea
  • Blood in stool
  • tenesmus

Abdominal pain, peripheral arthritis and ankylosing spondylitis less common
Fever, weight loss, constipation, ocular and cutaneous manifestations uncommon

History

Family history of IBD
Infection - 50% of relapses of colitis are associated with enteritis due to recognised pathogens

Vital signs / observations

Pyrexia - >37.8
Tachycardia - HR> 90bpm

Examination

  • Abdominal examination – Tenderness, pain, rebound tenderness

Bedside tests

Stool culture as most relapses are associated with pathogens
Blood pressure
Temperature
Heart rate

Laboratory investigations

FBC - look for anaemia, Hb < 10.5 gm/dL
LFTs (to detect primary sclerosing cholangitis), U&Es: May reveal hypokalaemic metabolic acidosis secondary to diarrhoea and elevated sodium and urea secondary to dehydration
Raised ESR and CRP
Faecal calprotectin elevated
Serological markers

  • pANCA and ASCA
  • About 70% of patients with UC have positive pANCA and about 70% of patients with Crohn's disease have positive ASCA

Radiological investigations

Diagnosis is reached with a combination of investigations but endoscopy or flexible sigmoidoscopy with biopsy and negative stool culture is indicative of a diagnosis

Plain abdominal radiograph - rules out perforation or toxic megacolon at initial presentation. May reveal dilated loop secondary to ileus, toxic megacolon where transverse colon is >6cm in diameter

Flexible sigmoidoscopy
Colonoscopy

  • Affects the rectum and spreads proximally
  • Rectal involvement
  • Continuous uniform involvement
  • Loss of vascular marking
  • Diffuse erythema
  • Fistulas rarely seen
  • Normal terminal ileum except in backwash ileitis

Biopsies obtained at time of endoscopy

  • Continuous distal disease
  • Mucin depletion
  • Absence of granulomata
  • Anal sparing

Management

Vaccination due to the immunosuppressive effect IBD treatments - consider influenza, pneumococcal polysaccharide vaccine, HBV, HPV, VZV

In cases of massive bleeding and >10 bowel movements daily admit patient and begin parenteral corticosteroids

Give IV fluids and electrolytes to reverse dehydration

Withdraw anticholinergic, antidiarrheal, NSAIDs and opioids as these can precipitate colonic dilatation

Treatment can then be divided into inducing and maintaining remission.

The severity of UC is usually classified as being mild, moderate or severe using the Truelove and Witts' severity index:
mild: < 4 stools/day, only a small amount of blood
moderate: 4-6 stools/day, varying amounts of blood, no systemic upset
severe: >6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers)

Inducing remission

Treatment depends on the extent and severity of disease
Mild Proctitis and proctosigmoiditis (distal colitis)

  • Topical aminosalicylate alone
  • Consider adding an oral aminosalicylate to a topical aminosalicylate
  • Oral aminosalicylate alone, although this is not as effective as a topical aminosalicylate alone or combined treatment

*Topical corticosteroids if aminosalicylates are not tolerated

Mild left-sided or extensive ulcerative colitis

  • Oral aminosalicylate

mesalazine has been shown to be superior to rectal steroids and oral aminosalicylates
oral aminosalicylates
oral prednisolone is usually used second-line for patients who fail to respond to aminosalicylates. NICE recommend waiting around 4 weeks before deciding if first-line treatment has failed
severe colitis should be treated in hospital. Intravenous steroids are usually given first-line

Add prednisolone if remission is not induced with aminosalicylates or corticosteroids

Severe UC

  • IV corticosteroids
  • IV ciclosporin if corticosteroids are not tolerated
  • Add IV ciclosporin to IV corticosteroids if initial treatment fails
  • Consider surgery

Maintaining remission

Proctitis and proctosigmoiditis
*Topical aminosalicylates alone or oral aminosalicylates e.g. mesalazine with a topical aminosalicylates
Mild left-sided or extensive ulcerative colitis

  • Low dose of oral aminosalicylates

For all patients
*Azathioprine and mercaptopurine if the patient has had two or more inflammatory exacerbations in the last 12 months of if remission is not maintained by aminosalicylates
methotrexate is not recommended for the management of UC (in contrast to Crohn's disease)
there is some evidence that probiotics may prevent relapse in patients with mild to moderate disease

Follow up

Surveillance colonoscopy for colorectal cancer beginning 8 to 10 years after disease onset.

  • Patients with long-standing UC are at increased risk for development of dysplasia.
  • Risk of colorectal cancer increases with longer duration and extensive severe colitis, family history of colorectal cancer, young age at onset of disease, presence of backwash ileitis, and history of primary sclerosing cholangitis
  • Regular LFTs to monitor for primary sclerosing cholangitis
  • DEXA scan due to increased risk of osteoporosis

Complications

Pyoderma gangrenosum - can also occur at stoma sites
Pseudopolyps - note these are not dysplastic and are not a risk factor for colon cancer
Benign Strictures
Colonic adenocarcinoma
Primary sclerosing cholangitis

Prognosis

Overall mortality does not appear to be increased in patients with UC compared with the general population
The most common cause of death remains toxic megacolon

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