Ulcerative colitis

Ulcerative colitis
Definition: Ulcerative colitis (UC) is a relapsing and remitting inflammatory condition of the large bowel, with unknown aeitiology.

Ulcerative colitis is moderately common with a prevalence of 100-200 per 100 000. It is 3 times more common than crohns, and is more common amongst Caucasians, and tends to affect women more than men. It has a bimodal distribution, most commonly affecting people between the ages of 15-30 with a smaller peak between 55-65.

Risk factors:

·      Ulcerative colitis is thought to be autoimmune

·      Family history of parent, children or sibling with ulcerative colitis increases the risk of an individual developing it.

·      Smoking is protective in ulcerative colitis, and UC is 3 times more common in non smokers.

Presentation:
Ulcerative colitis tends to present with gradual onset of bloody diarrhea associated with cramping abdominal discomfort and increased bowel frequency.

It may present acutely with systemic symptoms including severe adominal pain and diarrhea, fever, malaise, anorexia, and weight loss. Disease affecting the rectum can also cause tenesmus (feeling like the need to empty bowels but being unable to) and urgency.

Ulcerative colitis may also present with extraintestinal signs which includes:

• ·      Eye manifestations – episcleritis, scelritis and anterior uveitis
• ·      Clubbing
• ·      Apthtous ulcers
• ·      Enteropathic arthropathy( large joint mono or oligoarthropathy, or spondyloarthropathy or sacroilititis)
• ·      Clubbing
• ·      Erythema nodosum
• ·      Pyoderma gangrenosum
• ·      Liver disease- fatty liver, primary sclerosing cholangitis, cholangiocarcinoma
• ·      Renal stones (due to reduced absorption of fat which increases oxalate absorption and renal oxalate excretion causing oxalate sones)
• ·      Osteomalacia
• ·      Malnutrition
• ·      Amyloidosis

Examination findings

Patients with ulcerative colitis may have no signs on examination. In acute ulcerative colitis, patient may have a fever, with signs of dehydration (tachycardia, tachypnoea, dry mucous membranes etc). They may be anaemic, with pallor. They may also have a abdominal distension and tenderness.

Signs of extraintestinal disease may be present. 
 
Differential diagnoses
Other causes of changes in bowel habits include:
Crohns

Infective colitis (eg. C difficile infection)

Irritable bowel syndrome (alarming symptoms such as blood in stools or night time urgency not present)

Diverticular disease

Colon cancer (especially in older individuals)

Investigations

Bloods:

• FBC (may show anaemia, WCC may be raised in toxic megacolon), ESR and CRP (raised), urea and electrolytes (dehydration may cause abnormalities),  Liver function tests (albumin levels sometimes drop). Iron studies, B12 and folate may also be appropriate.
• Serum antibodies – pANCA is associated with UC.
• Stool microscopy and cultures – to exclude infections – eg. C difficile, salmonella, shigella etc. patients with inflammatory bowel disease may have a higher prevalence of C. diff infections, so its presence does not rule out diagnosis.
• Faecal calprotectin – shows colonic inflammation, may differentiate this from irritable bowel syndrome. 

Imaging:

•  Abdominal x ray may show colonic dilatation with mucosal thickening/islands which may indicate toxic megacolon.
• Chest x ray may show gas under the diaphragm in a perforation.
•  Sigmoidoscopy and rectal biopsy
• Colonoscopy – gold standard for diagnosis but may increase risk of bowel perforation in moderate to severe disease.
•  Do not do barium enemas during severe acute attacks or to diagnoses UC.

Other investigations may include:
ultrasound, CT, MRI, radionuclide scanning.

Management

Ulcerative colitis can be categorized into mild, moderate or severe disease based on the Truelove and Witts severity index in adults or the pediatric ulcerative colitis activity index in children.

mild	moderate	Severe
Less than 4 stools a day, little rectal bleeding, apyrexia (measured at 6am), with a pulse rate less than 70. ESR less than 30mm/h and haemoglobin over 11g.DL	4-6 stools a day with moderate blood in stools. Low grade or no fever (37.1-37.8 ºC)  with a pulse of 70-90. Haemoglobin between 10.5-11g/dL and normal ESR and CRP.	6 or more stools a day with visible blood in stools. Signs of systemic illness including fever over 37.8ºC, pulse over 90bpm, anaemia with Hb under 10.5g/dL and raised ESR (over 30mm/h) or CRP

Management of ulcerative colitis depends on the severity of the disease at presentation. Although it should be managed through a multidisciplinary team in the long run, with appropriate patient education.

Patient should be admitted to hospital if:

• ·      They have signs and symptoms of severe ulcerative colitis
• ·      They have moderate UC which does not respond within 2 weeks
• 
  

Medical management (based on NICE guidiance)

Mild- moderate ulcerative colitis affecting the anus or anus and sigmoid only

Offer topical aminosalicylates (eg. mesalazine) as first line to induce remission, adding oral aminosalicyclate or treating with only oral aminosaicyclate if necessary.

Topical corticosteroids or oral prednisolone can be used to induce remission where aminosalicyclate cannot be used.

Consider adding oral prednisolone to aminosalicylate to induce remission if no improvement is seen after 4 weeks or symptoms worsen. Consider adding tacrolimus where oral prednisolone is ineffective.

Aminosalicylate can be used to maintain remission. This is most effective if it is given topically, or as a combination of an oral medication and topical medication. New aminosalicylates have less side effects but are thought to be less effective and more expensive.

Azathioprine and mercaptopurine can be used to maintain remission where frequent exacerbations of ulecerative colitis occurs requiring corticosteroids (more than 2 episodes per year) or if aminosalicylates are ineffective at maintaining remission.

Extensive mild-moderate ulcerative colitis

Offer high dose oral aminosalicylate as first line treatment for inducing remission. Considering adding topical aminosalicylate or oral beclomethasone dipropionate.

Use oral prednisolone where aminosalicyclates are contraindicated.

Offer oral aminosalicylate to maintain remission. Again azathioprine and mercaptopurine can be used as second line drugs.

Acute severe ulcerative colitis

Acute severe UC should be managed by the gastroenterologists and colorectal surgeons, via a multidisciplinary team. Patient should be resuscitated with IV fluids and be nil by mouth. The patient should have regular obs and a stool chart, and be examined twice daily. Bloods should be repeated daily with abdominal xray if necessary. IV corticosteroids should be used first line to induce remission, and the need for surgery should be assessed.

Consider ciclosporins second line or surgery if IV corticosteroid are contraindicated or not tolerated. Ciclosporins can also be used if symptoms worsen or if no improvement is seen after 72 hours. Ciclosporin has a high toxicity with a mortality rate of 3% and should be considered carefully before use.

Infliximab can also be considered where ciclosporins are contraindicated.

Maintenance of remission is same as mild-moderate UC (with topical or oral aminosalicyclate depending on the extent of the disease).

Surgical management:
Colectomy or proctocolectomy will treat ulcerative colitis where it cannot be managed medically or due to colon cancer.

Complications:
Perforation

Bleeding

Toxic megacolon

Increased colonic cancer risk (about twice of general population) – screening via colonoscopy in high risk groups is available.

Prognosis
Ulcerative colitis is a chronic condition and is associated with reduced life expectancy. About 20% of patients will require surgery at some stage in their illness.

 http://upload.wikimedia.org/wikipedia/commons/c/cf/UC_granularity.png

http://upload.wikimedia.org/wikipedia/commons/8/8a/Ileostomy002.jpg
http://upload.wikimedia.org/wikipedia/commons/d/dd/Cigarette_smoke.jpg
Longmore M, Wilkinson IB, Davidson EH, Foulkes A, Mafi AR, Oxford handbook of clinical medicine, 8th ed. oxford, oxford university press, 2010. 

http://pathways.nice.org.uk/pathways/ulcerative-colitis

http://www.patient.co.uk/doctor/ulcerative-colitis-pro