ULCERATIVE COLITIS (UC)

What is UC

Chronic, relapsing-remitting, inflammatory disease of the GI tract - rectum

and colon

Non-infectious - not causes by pathogens so does not spread

Continuous - will affect a part of the colon continously (not one part, then
miss and then another part)

Has a range of extra-intestinal manifestations

NEVER spreads into small intestines or anus

What is the epidemiology of UC

Most common form of IBD

Bimodal distribution - highest incidence is in 15-25 and 55-65 age groups

What is the aetiology of UC

Polygenic predisposition (more than one gene causes it)

Environmental factors

Immune dysfunction

Inflammation extends from rectum proximally to affect a variable length of

continuous colon

What part of the anatomy does UC affect

Affects the large bowel - mainly colon and rectum

Large bowel - caecum, colon, rectum and anal canal

Colon - ascending colon, transverse colon, descending colon, sigmoid colon

Ileocaecal valve - between the ilium and the colon

Below the ileocaecal valve is the caecum

Above the ileocaecal valve is the colon

In UC, the inflammation starts at the rectum and never spreads beyond the
ileocaecal valce

ULCERATIVE COLITIS (UC) 1

 Can affect just the rectum (ulcerative proctitis), the left-side of the colon (left-
sided colitis) or the whole colon (pancolitis)

Ulcerative proctitis is more common - only within rectum

Left-sided colitis - inflammation involves rectum and doesnt extend beyond

splenic flexure

Pancolitis - inflammation extends from rectum to ileocaecal valve

What is the pathophysiology of UC

Microscopically

Acute and chronic inflammatory cells invade lamina propria

Affects just the inner layer of mucosa

Crypt branching

Villous atrophy

Neutrophils migrate through walls of glands to form crypt abscesses

No granulomas present

Depletion of goblet cells and mucin from gland epithelium

No inflammation beyond submucosa

Widerspread ulceration with perservation of adjacent mucosa - appearance

of polyps (pseudopolyps)

What are pseudopolyps

Masses of scar tissue - develop from granulation tissue during the healing
phase in repeated cycle of ulceration

Project out of wall

Marker of episodes of severe infection

What are the risk factors of UC

Family history - 1 degree relatives of someone with UC have a higher

chance of developing UC compared to those without a UC relative

Oral contraceptives - association between use of oral contraceptives and

development of IBD

Not smoking - risk of UC is less in smokers

ULCERATIVE COLITIS (UC) 2

 What are the intestinal symptoms of UC

Diarrhoea - can contain mucus and blood

Left iliac fossa/ LUQ pain

Pale - anaemia due to blood in stool

Urgency

Tenesmus - feeling that you need to pass stools even though bowels are
empty, can involve straining, pain, cramping

Systemic symptoms - malaise, fever, weight loss

What are the extra-intestinal symptoms of UC (that are related to disease

activity)

Dermatological manifestations - erythema nodosum

Occular manifestations - episcleritis

MSK manifestations - osteoporosis, arthritis (that is pauciarticular (affects

only a few joints), non-deforming, assymetrical)

Aphthous ulcers

What are the extra-intestinal symptoms of UC (that are not related to disease
activity)

Dermatological manifestations - pyoderma gangrenosum

Occular manifestations - anterior uveitis, conjuctivitis

MSK manifestations - clubbing, sacroilitis

Hepatobiliary manifestations - primary sclerosing cholangitis (PSC - more

common in UC compared to CD and more common in males)

Ankylosing spondylitis

AA amyloidosis - secondary to chronic inflammation, rare and serious

What are the clinical signs of UC

Distension of adbomen on palpitation

Tenderness of adbomen on palpitation

PR exam - tenderness, blood, mucus

How is the severity of UC assessed

ULCERATIVE COLITIS (UC) 3

 Truelove and Witts’ Severity Index

FAB CHEF - what the severity index focuses on (acronym has no order, just
to remember the different components of the severity index)

Frequency of stools in a day

Anaemia

Blood in stool - how much

CRP

HR

ESR

Fever

Mild - under 4 stools a day, small amounts of blood stool, no anaemia or

fever, HR below 90, normal ESR/CRP

Moderate - 4-6 stools a day, blood in stool (more than in mild), no anaemia
or fever, HR below 90, normal ESR/CRP

Severe - over 6 stools a day, visible blood in stool/alot of blood, one feature
of systemic involvement (fever, HR above 90, ESR above 30, CRP can be
raised sometimes)

What investigations are done for UC

Bloods

Stools

Imaging such as AXR, erect CXR

Barium enema - loss of haustrations, superficial ulceration, pseudopolyps,

lead pipe/ drain pipe colon (colon is narrow and short)

Rigid/flexible sigmoidoscopy - with biopsy, can check for toxic megacolon

Colonoscopy with multiple biopsies - first line to diagnose colitis

Which bloods are done for UC

FBC - leukocytosis in flare up

ESR/CRP - can increase in active disease

U&E’s

ULCERATIVE COLITIS (UC) 4

 LFT’s - check 6-12 months to screen for PSC

Which stool tests are done for UC

Culture and microscopy

Faecal calprotein

A small calcium binding protein

Raised in IBD

Concentration of calprotein in faeces can correlate with severity of

disease

Helps to differentiate from IBS

Which imaging is done for UC

AXR - can assess extent of colonic involvement in acute severe colitis, can
show lack of faecal shadows, mucosal thickening or toxic megacolon

Erect CXR - rule out perforation in acute severe colitis

What can be found on a colonscopy with biopsy

Red and raw mucosa

No inflammation beyond submucosa

Pseudopolyps may be seen

Crypt abscesses (occur due to neutrophil migration)

What is the general rules for managing UC

Management will depend on severity and location of UC

If UC is mild to moderate - oral steroids

If UC is acute and severe - first line is IV steroids, second line is IV

Cyclosporin

What is the management for UC when inducing remission

Topical rectal aminosalicylayes or rectal steroids

For distal colitis - rectal Mesalazine works better than rectal steroids and oral
aminosalicylates

Oral aminosalicylates

ULCERATIVE COLITIS (UC) 5

 Second line for those who don’t reespond to aminosalicylates - oral
Prednisolone

Severe colitis - IV steroids

Infliximab - moderate to severe UC, when disease is resistant to

conventional treatment that uses corticosteroids and immunosuppressive
agents

What is the management for UC to maintain remission

Oral aminosalicylates such as Mesalazine

Azathioprine and Mercaptopurine

Probiotics may help to prevent relapse in those with mild-moderate disease

What surgical treatment is available for UC

Surgery is curative of UC

Colectomy

Indications for surgical intervention - patients who fail to respond/intolerant of

treatment, if complications occur such as colorectal cancer

What are the complications of UC

Psychological effects

Toxic megacolon

Colorectal cancer such as colonic adenocarcinoma

VTE - venous thromboembolism (VTE includes both DVT and PE)

Perforation

Strictures and obstructions - bowel loops can develop strictures following

chronic inflammation, strictures can lead to obstruction

Some forms of extra-intestinal manifestations such as AA amyloidosis,

osteoporosis (due to steroid use)

What is toxic megacolon

Acute form of colonic distension

Can become septic and perforate

Requires supportive care, bowel rest, NG decompression and antibiotics

ULCERATIVE COLITIS (UC) 6

 Needs colectomy if no improvement within 24-48 hours

ULCERATIVE COLITIS (UC) 7