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What is Ulcerative Colitis

Ulcerative Colitis is a chronic Inflammatory Disorder caused by overreaction of the immune system to gut bacteria. UC, along with Crohns disease, is an inflammatory bowel condition. The rectum is normally first affected, and the disease tracks up to the ileocecal valve

UC is a non-granuloma forming condition (as opposed to Crohns) that only ever affects the colon and rectum up to ileocecal valve. Ulcers only form in the mucosa and submucosa (not transmural) and the area affected is continuous (with no skip lesions). Ulcerative Colitis is a lifelong condition that undergoes periods of flare ups and remission.

Patients with UC are at risk of a Toxic Megacolon (an acutely inflamed dilated colon presenting with fever, abdominal pain, tachycardia, dehydration) which can lead to secondary perforation. Chronic complications include an increased risk of colorectal cancer, primary sclerosing cholangitis or osteoporosis (from long term steroid use)


What will you find in a history of Ulcerative Colitis?

IBD should be suspected in patients who have bloody diarrhoea and/or diarrhoea with signs of systemic inflammation for >3 weeks.
Diarrhoea (Can be episodic or chronic)
Blood/Mucous in Stool
Abdominal Pain/Cramps - Commonly LLQ first (Rectum Affected First)
Extra intestinal manifestation – Erythema Nodosum, Pyoderma Gangrenosum, Conjunctivitis/Episcleritis/Iritis, Large Joint arthritis, Sacroiliitis, Ankylosing Spondylitis, Primary Sclerosing Cholangitis
Systemic (Normally present during flare ups) – Fever, Malaise, Anorexia, Weight Loss

Risk Factors:
Aged Commonly 15-30
Smoking is protective – Patients who have just quit smoking may have a first presentation or flare up
Associated with Primary Sclerosing Cholangitis
Family History

Specific Questions to ask:
Assess number of bowel movements per day to assess severity
Ask if pain is relieved on defecation – More likely to be IBS

GI questions to ask:
Nausea and vomiting
Weight loss
Abdominal Pain
Change in bowel habit

Crohn's disease - Crohn's disease often has perianal involvement, is less likely to present with rectal bleeding and more likely to form fistulae. Differentiated by endoscopy. If unsure can be named Indeterminate colitis
Bacterial/Viral Gastroenteritis - History of recent exposure or travel. Self-limiting and will go away, Differentiated by stool cultures
Infectious Colitis
Irritable bowel syndrome - Lower abdominal pain and bloating, relieved by defecation, normal inflammatory markers
Diverticulitis - Commonly presents with left-sided abdominal pain in patients aged 50 years and older.
C. diff infection - Recent hospital stay
Ischaemic Colitis - Most patients have risk factors such as atherosclerotic diseases or older patients, pain will be much worse and may be one big bleed.


What will you find on an examination of Ulcerative Colitis

End of the bed:
Large Joint Arthritis
Ankylosing Spondylitis
Signs of anaemia or malnutrition
Pale conjunctiva - From anaemia
Tenderness in LLQ
Peritonitis indicates perforation
Erythema Nodosum
Pyoderma Gangrenosum
During flare ups:
Weight Loss
Distended tender Abdomen


What are the investigations used for Ulcerative Colitis and what will they show?

Bedside Tests:
Stool cultures (send multiple samples)– A negative stool culture is required for diagnosis, also helps to rule out infective causes. Make sure to test for C. diff
Full set of observations

FBC - Looking for underlying infection or anaemia
ESR/CRP – Correlate with disease activity
U&E – Looking for any signs of Dehydration (or secondary AKI), Diarrhoea may cause low electrolyte levels, specifically hypokalaemia
LFT - liver tests should be checked every 6 to 12 months for surveillance of primary sclerosing cholangitis (Raised ALP). May also show low albumin levels if malnutrition
Ferritin - Iron deficiency due to malnutrition
Blood Cultures - Looking for infection
B12 and Folate levels - Malnutrition
ABG – Only if severe disease to look for Metabolic Acidosis caused by severe diarrhoea

Abdominal X-ray – Used in severe flare ups to assess for any colonic dilation or colonic islands (Seen in Toxic Megacolon)
Colonoscopy with Biopsies - Diagnostic Test used to differentiate UC and Crohns. Seek advice during flare ups due to increased risk of perforation during scoping. May just used flexible sigmoidoscopy in these cases. This colonoscopy should be done 10 yearly to assess disease progression

Special Tests:
Faecal Calprotectin - Rule out irritable bowel syndrome


What is treatment of Ulcerative Colitis Flare Ups

A-E approach
Get IV Access/Give O2 to maintain sats of 94+ /Attach 12 lead ECG
Assessment with AMPLE history and brief examination
Get help - Medical reg on call
Frequent Observations - Constant or 15 minutely
Daily bloods/abdominal examination in severe flare ups (to look for toxic megacolon/sepsis)

Medical: - Do not use anti-diarrhoeal medications in UC patients as predisposes toxic megacolon
Mild - Oral Mesalazine (Try PR Mesalazine in rectal only UC – More bleeding, less systemic symptoms). If needed add steroids (Hydrocortisone Topical Rectal Foam or Prednisolone enema)
Moderate - Oral Prednisolone titrated down over 7 weeks. If no improvement after 2 weeks admit and treat as severe

Admit Patient
IV and rectal steroids Hydrocortisone
If not improved within 72 hours consider ciclosporin or infliximab
Electrolyte replacement if indicated
VTE prophylaxis (IBD patients are at increased risk of VTE – Unknown cause)
If no improvement by day 7-10 may need a colectomy
CRP >45 or >6 stool per day after day 3 indicates surgery will likely be needed at the 7-10 day mark


What is the treatment for Ulcerative Colitis Maintenance

Refer to dietitian
Avoid Precipitating foods - Spicy foods, alcohol, caffeine, dairy products and fibre are all known precipitants
Drink plenty of fluids
Try to reduce stress- can worsen symptoms e.g. do exercise, mediation
1-5 yearly colonoscopy surveillance for colorectal cancer

Oral and/or topical Mesalazine once daily
Add Oral Azathioprine if not controlled (>2 flare ups/year)
Add on treatment after this is Infliximab

Only indicated in failed medical treatment
Subtotal colectomy with terminal ileostomy with stoma or ileoanal pouch.
Removal of the colon. The rectum is closed with sutures and left inside the abdomen, this is known as a Rectal Stump.
The end of the small bowel (ileum) is brought out onto the surface of the abdominal wall this is called an Ileostomy.
Pouch reverses stoma but may still have <6 stools daily and recurrent pouchitis, so leave up to the patient


How do you grade severity of Ulcerative Colitis

<4 stools, small amount of blood, no anaemia, HR<90, no fever or raised inflammatory markers. HR<70

4-6 stools, moderate blood in stool, no anaemia, HR<90, no fever or raised inflammatory markers. HR 70-90

>6 stools, visible blood, one systemic feature of above. HR <90