Download Ulcerative Colitis

What do these people all have in common?
Stewart Lee - comedian
Sir Steve Redgrave – Olympic rower
William Wilberforce – abolition of the slave trade
ULCERATIVE COLITIS
EPIDEMIOLOGY
• Most common IBD
• Incidence = 10 in 100 000
• Prevalence = 240 per 100 000
• Age of onset
– Peak incidence: 15 -25 years
– Second smaller peak 55-65 years
• M=F
AETIOLOGY
• UNKNOWN - ?autoimmune
• Risk factors:
– Genetics – FHx of UC or CD
– Developed countries
– Ethnicity – Caucasian (Northern Europe and America)
• Smoking – protective
PATHOGENESIS
• Genetically susceptible host – MDR1 gene variants
• Increased immune response to enteric commensal bacteria
–Innate immune system – macrophages, neutrophils
–Acquired immune system – T cells, B cells
–Release of inflammatory cytokines
• Environmental factors – stress, infection, NSAIDs
SYMPTOMS
• Bloody, mucoid diarrhoea/rectal bleeding
• Colicky abdominal pain
• Urgency
• Tenesmus
• Constipation
• Weight loss
• Malaise
• Extra-intestinal symptoms:
– Joints – sacroiliitis, ankylosing spondylitis
– Skin – pyoderma gangrenosum, erythema nodosum
– Eyes – anterior uveitis
SIGNS
• Guarding on abdominal palpation
• Thin, pale
• Tachycardia
• Pyrexia
• Signs of anaemia
DIAGNOSIS
• Stool sample - raised faecal calprotectin = suggestive of colonic inflammation
• Bloods - raised ESR/CRP, anaemia
• AXR (rule out toxic megacolon)
• Colonoscopy with multiple biopsies
– Continuous inflammation of mucosa from rectum
– Only in the colon (vs CD) – may be backwash ileitis
– No skip lesions, granulomas, deep ulcers, strictures, fissures or fistulas
TREATMENT
• Aminosalicylates – mesalazine (topical and/or oral)
– Induction and maintenance of remission
• Corticosteroids – prednisolone (topical or oral)
– Induction of remission (relapse, severe)
• Thiopurines – azathioprine
– Corticosteroid intolerance/regular relapses
• Surgery – colectomy in 30%
– Unresponsive to treatment, complications (toxic megacolon, colorectal neoplasia)
PROGNOSIS
• Relapsing-remitting course, variable
• Social stigma of colostomy bag, using disabled toilets
• 2x increased risk of colorectal cancer
• Surveillance colonoscopy after 10 years of disease, every 1-5 years dependent
on risk
• Colectomy for high-grade dysplasia
CASE STUDY
• 15 year old male
• Reports frequently passing
stool with abdominal
discomfort
• What else should you ask?
CASE STUDY
• How many times a day?
• Any blood? Every time or just sometimes? Fresh/mixed in?
• Mucus?
• Associated nausea/vomiting?
• Recent travel?
• Food triggers?
• Weight loss?
• Mouth ulcers? Rectal fissures?
• Extra-intestinal symptoms?
CASE STUDY
• Investigations:
– Bloods – FBC, CRP/ESR, U&E, LFT, coeliac screen
(tTG)
– Stool sample – faecal calprotectin, culture (OCP)
– Imaging – AXR, ?CT/MRI
– Endoscopy – colonoscopy with biopsy
• Management:
– Induce remission – mesalazine +/- prednisolone
– Maintain remission – mesalazine
– Monitor regularly, recognition of relapse
MCQ
What is the peak age of onset of ulcerative colitis?
A. 5-15
B. 15-25
C. 25-35
D. 35-45
MCQ
Which of the following is NOT a risk factor for developing UC?
A. Gastrointestinal infection
B. MDR-1 gene variation
C. Stress
D. Smoking
MCQ
Which of the following may be a sign of UC?
A. Pale stools
B. Vomiting
C. Weight loss
D. Bradycardia
MCQ
Which of the following is first-line treatment for induction of
remission in UC?
A. Azathioprine
B. Mesalazine
C. Mercaptopurine
D. Budesonide
MCQ
What is the peak age of onset of ulcerative colitis?
A. 5-15
B. 15-25
C. 25-35
D. 35-45
MCQ
Which of the following is NOT a risk factor for developing UC?
A. Gastrointestinal infection
B. MDR1 gene variation
C. Stress
D. Smoking
MCQ
Which of the following may be a sign of UC?
A. Pale stools
B. Vomiting
C. Weight loss
D. Bradycardia
MCQ
Which of the following is first-line treatment for induction of
remission in UC?
A. Azathioprine
B. Mesalazine
C. Mercaptopurine
D. Budesonide
SUMMARY
• Most common type of IBD
• Multifactorial aetiology
• Relapsing-remitting course
• Bloody diarrhoea/rectal bleeding = most common symptom
• Diagnosis = colonoscopy with biopsies
• Treatment:
– Remission with mesalazine +/- prednisolone
– Maintenance with mesalazine
• Increased risk of colon cancer and toxic megacolon -> colectomy
SUMMARY
SUMMARY: UC VS. CROHN’S?
CROHN’S DISEASE
ULCERATIVE COLITIS
ORIGIN
Terminal ileum
Rectum
PROGRESSION PATTERN
Skip lesions, irregular
Proximally contiguous
INFLAMMATION
Transmural
Submucosa or mucosa
SYMPTOMS
Crampy Abdominal pain
BLOODY DIAHRRHEA
COMPLICATIONS
Fistulas, obstruction, abscess
Toxic megacolon, Hemorrhage
RADIOGRAPHS
String Sign: Barium X-ray
Lead pipe colon: Barium X-ray
SURGERY
Certain complications (Strictures)
Can be CURATIVE
SMOKING
HIGHER RISK
LOWER RISK
COLON CANCER RISK?
SLIGHT Increase
MARKED Increase
IBS Vs. IBD
THANK YOU! ANY QUESTIONS?
REFERENCES
• Ulcerative Colitis - http://patient.info/doctor/ulcerative-colitis-pro
• Mechanisms of Disease: Pathogenesis of Crohn's Disease and Ulcerative Colitis http://www.medscape.com/viewarticle/540142_7
• Pathology Outlines - http://www.pathologyoutlines.com/topic/colonuc.html
• NHS choices - http://www.nhs.uk/Conditions/Ulcerative-colitis/Pages/Treatment.aspx
• NICE guidelines for UC - https://pathways.nice.org.uk/pathways/ulcerative-colitis#content=viewnode%3Anodes-step-1-therapy-left-sided-and-extensive-ulcerativecolitis&path=view%3A/pathways/ulcerative-colitis/inducing-remission-in-people-with-ulcerativecolitis.xml