CONDITIONS - Ulcerative Colitis

1. Definition

Ulcerative colitis is a chronic form of inflammatory bowel disease that affects the colonic mucosa from the rectum proximally.

2. Epidemiology

Increased incidence in Caucasians compared to Afro-Caribbean or Asian populations
Increased incidence in the Ashkenazi - Jewish population
The incidence is approximately 10-20:100,000 population per year in the UK
Prevalence - 100 - 200 per 100,000
May affect any age group. Bimodal distribution - peaks are ages 15 to 30 and 50 to 70
 
3. Risk Factors

Family history - Risk is approximately 10-20% for individuals with a first degree relative
Smoking is PROTECTIVE against UC.
  
4. Symptoms and Signs

Acute severe attack of UC may be defined clinically by the presence of
>6 bloody diarrhoeal stools/day (primary symptom)
Pyrexia
Tachycardia
Anaemia
Weight loss
Abdominal pain/tenderness

Click here to see the National Association for colitis and Crohn's disease
 
4.1 Extra-intestinal manifestations of UC
4.1.1 Related to disease activity
Pyoderma gangrenosum
erythema nodosum
mucous apthous ulcers
iritis
large joint arthritis
 
4.1.2 Unrelated to disease activity 
Sacroileitis/ankylosing spondylitis
chronic active hepatitis
cirrhosis
primary sclerosing cholangitis (more common in UC than Crohn's)
primary biliary cirrhosis
clubbing

5. Diagnosis + Investigation
 
History and Examination
Digital Rectal Exam (DRE)
Bloods: Haemoglobin, platelets, ESR,CRP, serum albumin
Stool culture - MC&S + C-Diff toxin
Rigid Sigmoidoscopy without excessive air insufflation
AXR - for colonic dilatation (toxic megacolon) + thumbprinting
Erect CXR - if you suspect a perforation
Sigmoidoscopy/Colonoscopy - Extent of colitis + biopsies can to taken to make a histological diagnosis 
Diagnosis is made by combining the history and examination findings with colonoscopy, histology and negative stool samples.
 
6. Pathology (see table comparing to Crohn's)
 
6.1 Macroscopic
Starts from the rectum and spreads proximally involving avariable but continuous length of colon
May involve the entire colon (pancolitis)
Ileum involved in one third on cases (backwash ileitis)
Inflammation and ulceration usually limited to mucosa
Shallow mucosal ulcers
Mucosal surface covered in blood and mucous with numerous petechial haemorrhages
 
6.2 Microscopic
Distortion of crypt architecture
Inflammation of the crypts (cryptitis)
Numerous crypt abscess
Other rare types include SCC and lymphoma

6.3 Risk of dysplasia or malignant change
This increases with the length of history
7% at 10 years
17% at 30 years
Total colitis patients have a much higher risk than those with only left-sided disease (19 fold versus 4 fold) increase compared to the normal population.

7. Management

7.1 Acute UC
Treatment is initially supportive
IV fluid replacement
Blood transfusion if required
DVT Prophylaxis
Nutritional support
Drugs
 
7.2 Drugs used to induce remission
5-aminosalicylic acid derivatives (e.g. mesalazine (topical or oral), sulfasalazine)
induces remission
for mild to moderate colitis, is an efffective first line therapy
Corticosteroids (e.g. iv hydrocortisone, prednisolone (oral or  enemas )
used to induce remission.
Combination of oral and rectal steroids is better than either alone.
Thiopurines (e.g. azathioprine)
Effective for both active disease and maintaining remission
Cyclosporin
Used as salvage therapy for patients with refractory colitis.
Use is controversial due to side effect profile e.g. renal impairment, neurotoxicity, infections
 
7.3 Maintaining Remission
Lifelong maintenance therapy generally recommended
5-aminosalicylic acid derivatives (mesalazine) - main role in UC is maintenance of remission
Thiopurines - main role is steroid sparing. Careful monitoring required to look for evidence of bone marrow suppression and hepatotoxicity
 
7.4 Indications for Surgery
Patients requiring surgery for IBD should be under joint care of a gastroenterologist and a colorectal surgeon.
Can be classified into Emergency or Elective

7.4.1 Emergency
7.4.1.1 Indications
Failure of medical management
Toxic dilatation
Perforation
Bleeding

7.4.1.2 Predictors of Surgery
Re-evaluation required at day three of admission with acute attack
Predictors of surgery on day three (85% of cases)
CRP >45
Stool frequency >8/day

7.4.2 Elective
Steroid dependence
Recurrent exacerbations
Rapidly relapsing disease
Growth retardation in children
Malignant transformation
Cancer prophylaxis
 
7.5 Surgical Options

7.5.1 Emergency
7.5.1.1 Subtotal Colectomy + end Ilestomy
Colon removed leaving rectal stump and end ileostomy
Performed in the emergency situation for UC
Advantages - Permits ileorectal anastomosis at a later date, or other sphincter preserving surgery
Disadvantages - will often need >1 operation for persistent proctitis, haemorrhage, cancer prophylaxis/transformation
click here to see a pathology specimen of fulminant colitis

7.5.1.2 Proctocolectomy + end Ileostomy
Whole colon + rectum removed and end ileostomy
Performed if patient adamant that does no require further surgery and happy to manage lifelong stoma
Advantages - single curative procedure, no further cancer surveillance required
Disadvantages - permanent end stoma + stoma complications (stenosis, hernia, prolapse)

7.5.2 Elective
7.5.2.1 Completion Proctectotomy/ proctocolectomy + ileoanal pouch reconstruction
Rectal stump removed (following sub-total colectomy)/ whole colon + rectum removed and ileo-anal pouch formed
Advantages - no stoma (very important to some patients as leads to improved quality of life), all disease removed, transanal defaecation and faecal continence preserved
Disadvantages - Pouchitis, nocturnal seepage, increased bowel movements (about 6 times/day), 2nd surgical procedure + complications involved

7.5.2.2 Colectomy and Ileorectal Anastomosis
Colon removed and ileorectal anastomosis formed
Advantages - single procedure, no stoma, transanal defaecation and faecal continence preserved
Disadvantages - Residual rectum with recurrent disease and cancer risk needing surveillance

8. Suggested further reading

National Assocation for Colitis and Crohn's
http://www.nacc.org.uk
BSG guidelines for management of IBD
http://www.bsg.org.uk/pdf_word_docs/ibd.pdf

The management of Ulcerative Colitis with Bod Goddard and Jon Lund

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