Ulcerative Colitis

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Ulcerative Colitis

• An Inflammatory Bowel Disease c.f. Crohn's Disease
• whole or part of colon, nearly always involves rectum
• inflammation confined to mucosa
• immunological, dietary or genetic factors
• familial clustering
• malignant change in colon with time

Presentation

• 25-30 years of age
• Diarrhoea
  • blood 
  • mucus
• Abdominal pain

Severe Attack

• >6 stools /day with blood
• temp >37.5
• pulse >90 bpm
• ESR >30mm/hour
• haemogolobin <10g/dl
• albumin <30g/l

History

Symptoms

• Diarrhoea
• rectal bleeding
• abdominal pain
• fever
• weight loss
• Time course
  • acute
  • fulminant
  • intermittent
  • chronic
• Other
  • dry, gritty eyes
  • arthralgia
  • rashes

PMH

• admission for toxic megacolon +/- surgery

SHx

• More common in non-smokers than Crohn's disease

Examination

• General
  • pallor
  • malnutrition / thin
  • febrile
  • erythema nodosum
  • pyoderma gangrenosum
  • arthritis
• Hands
  • clubbing
• Face 
  • conjunctivitis / uveitis
  • jaundice
• Mouth 
  • swollen lips
  • aphthous ulcers
• Abdomen
  • abdominal tenderness
  • abdominal distension
• Rectal
  • oedematous skin tags
  • fissuring
  • ulceration
  • fistulae

Investigations

• FBC
• ESR / CRP
• U&Es
• Albumin
• LFTs
  • hypoproteinaemia
  • abnormal due to sclerosing cholangitis
• AXR
  • acute toxic dilatation
  • perforation
• Barium enema
  • loss of haustrations
  • mucosal distortions
  • colonic shortening
  • stricture due to carcinoma
• Sigmoidoscopy
  • red, inflamed mucosa
  • contact bleeding
  • pseudopolyps
• Colonoscopy
  • +biopsy
  • to assess extent
  • exclude carcinoma
• Radiolabelled white cells

Pathology

• Extends proximally from rectum
• Red, inflamed mucosa
  • bleeds easily
  • inflammatory polyps
• Inflammation limited to mucosa
• Crypt abscesses

Complications

• Toxic dilatation
• haemorrhage
• stricture
• perforation
• carcinoma
• seronegative arthritis
  • sacroileitis
  • amkylosing spondylitis
• sclerosing cholangitis
• chronic active hepatitis
• uveitis
• amyloid

Treatment

Maitenance

• Diet
  • appropriate fibre
  • vitamins and iron
• suphasalazine or mesalazine

Mild relapse

• steroids
  • oral
  • retention enemas

Severe relapse

• IV fluids
• antibiotics
• parenteral steroids
• blood transfusion
• parenteral nutrition
• immunosuppressants
  • azathioprine

Indications for surgery

• acute toxic dilatation
• perforation
• failure to respond to medical treatment
• chronic disease
• severe arthritic symptoms
• carcinoma

Prognosis

• Mortality with toxic dilatation or perforation = 5%
• risk of colorectal cancer = 2% at 10 years, 30% at 30 years (colonoscopic surveillance every 2 years)

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