ppt on ulcerative colitis

1. Ulcerative colitis

2. Ulcerative colitis
• Ulcerative colitis (UC) is the most common form of
inflammatory bowel disease, the other major type
being Crohn’s disease (CD)
• It is most prevalent among the Caucasian population
• bimodal distribution
– between 15-25yrs for most cases
– smaller peak of incidence between 55-65yrs
• Prevalence in the UK is approximately 0.2%, with
males and females affected equally

5. • The disease typically follows a remitting and
relapsing course.
• A severe fulminant exacerbation may be life-
threatening, resulting in
– Severe systemic upset,
– Toxic megacolon,
– Colonic perforation
– even death

6. Pathophysiology
• Etiology: an interaction between genetic
factors and environmental triggers
• It is characterised by diffuse continual mucosal
inflammation of the large bowel, beginning in
the rectum and spreading proximally
• A portion of the distal ileum can become
affected in a small proportion of cases, termed
‘backwash ileitis’

9. • Histological changes include non-granulomatous
inflammation of the mucosa and submucosa,
crypt abscesses and goblet cell hypoplasia
• Repeated cycles of ulceration and healing may
lead to raised areas of inflamed tissue termed
‘pseudopolyps’
• Smoking is protective against UC, whilst a
positive family history of inflammatory bowel
disease is a strong risk factor

11. Classification

13. Clinical Features
• Ulcerative colitis is typically insidious in onset.
• The cardinal feature is bloody diarrhoea, with visible
blood in stool reported in more than 90% of cases.
• The most common manifestation of ulcerative colitis
is proctitis, whereby the inflammation is confined to
the rectum only.
• Patients may complain of PR bleeding and mucus
discharge, increased frequency and urgency of
defecation, and tenesmus.

14. • Patients presenting with more widespread colonic
involvement are more likely to experience bloody
diarrhoea with clinical features of dehydration
• Systemic symptoms also include malaise, anorexia,
and low-grade pyrexia
• Unless there is a severe exacerbation, clinical
examination is generally unremarkable
• Fulminant colitis, toxic megacolon, or colonic
perforation should be suspected if the patient
complains of severe abdominal pain, peritonism

15. Disease grading

16. • Musculoskeletal – enteropathic arthritis (typically
affecting sacroiliac and other large joints) or nail
clubbing
• Skin – Erythema nodosum (tender red/purple
subcutaneous nodules, typically on the shins)
• Eyes – Episcleritis, anterior uveitis, or iritis
• Hepatobiliary – Primary sclerosing cholangitis*
(chronic inflammation and fibrosis of the bile
ducts)

17. Investigations
• Routine bloods* (FBC, U&Es, CRP, LFTs, and clotting)
• NICE guidelines recommend that faecal calprotectin
testing is carried out in patents with recent onset lower
GI symptoms
• It is raised in inflammatory bowel disease, but
unchanged in irritable bowel syndrome
• A stool sample should be sent for microscopy and
culture
• Liver function tests
• Clotting test

18. • The definitive diagnosis for ulcerative colitis is via
colonoscopy with biopsy*.
• Characteristic macroscopic findings are of
continuous inflammation with possible ulcers
and pseudopolyps visible.
• The Montreal score can be used for quantifying
disease extent and the Mayo score for disease
severity.

19. • In acute exacerbations, plain film abdominal
radiographs (AXR) or CT imaging
• AXR features of acute ulcerative colitis flares
also include mural thickening and
thumbprinting, indicating a severe
inflammatory process in the bowel wall
• In chronic cases of UC, a lead-pipe colon is
often described (best seen on barium studies)

20. Management
• Patients with suspected IBD should be
referred to a gastroenterologist for
confirmation of the diagnosis and initiation of
treatment; those with acute severe disease
should be admitted on an emergency basis
• Anti-motility drugs, such as loperamide,
should be avoided in acute attacks, as these
can precipitate toxic megacolon

21. Inducing Remission
• Any acute attacks will also warrant aggressive
fluid resuscitation, nutritional support, and
prophylactic heparin (due to the prothrombotic
state of IBD flares).
• The medical management to induce remission in
UC typically requires use of intravenous
corticosteroid therapy and immunosuppresive
agents,such as ciclosporin or 5-ASA suppositories.

22. • Biological agents, such as infliximab, can be
trialled as rescue therapy if then needed.
• NICE guidelines suggest that a stepwise
approach is adopted, dependent upon the
clinical severity and location of the
exacerbation.

23. • Due to increased risk of colorectal malignancy,
colonoscopic surveillance is offered to people
who have had the disease for >10 years with >1
segment of bowel affected.
• Patients should be referred to IBD-nurse
specialists and patient-support groups.
• Enteral nutritional support should be considered
in young patients with growth concerns, with
close support from a nutritional team.

24. Surgical Management
• Approximately 30% of patients with ulcerative
colitis will at some point require surgery.
• Indications for acute surgical treatment
– Disease refractory to medical management
– Toxic megacolon
– Bowel perforation

26. Complications
• Toxic megacolon
• Colorectal carcinoma
• Osteoporosis
• Pouchitis