11/14/24, 10\:39 AM Ulcerative Colitis

Ulcerative Colitis

Table of contents
Key points ⚡
Succinct notes to superpower your revision
Ulcerative colitis\: chronic, relapsing-remitting in
form of in
Incidence\: bimodal distribution (15-30 years and 50-70 years).
Aetiology\: unclear, but involves altered intestinal microbiota and compromised colonic epithelial integrity; genetic,
environmental, and dietary factors play roles.
Risk factors\: family history of IBD, HLA-B27 positive, recent gastrointestinal infection, NSAIDs, smoking cessation, Ashkenazi
Jewish descent.
Symptoms\: diarrhoea ± blood ± mucus, urgency, tenesmus, lower abdominal pain, abdominal discomfort, bloating, fatigue,
weight loss, malaise; extra-intestinal manifestations (iritis, uveitis, episcleritis, erythema nodosum, pyoderma gangrenosum,
arthritis, osteoporosis, primary sclerosing cholangitis, nephrolithiasis, anaemia, thromboembolism).
Examination
erythema nodosum, pyoderma gangrenosum, uveitis, episcleritis.
Classi
clinical severity (mild, moderate, severe).
Di
bowel syndrome (IBS).
Investigations\:
Blood tests\: FBC (anaemia, raised WCC), U&Es, CRP (elevated), LFTs (hypoalbuminaemia), pANCA (if PSC suspected).
Stool tests\: faecal calprotectin (raised in UC), microscopy and culture (exclude infection).
Endoscopy (gold standard)\: sigmoidoscopy ± colonoscopy with biopsy (continuous in
mucosa, ulceration, pseudopolyps; crypt abscesses, decreased goblet cells).
Imaging\: plain abdominal X-ray (AXR), CT (exclude complications like toxic megacolon, bowel perforation).
Management\:
Medical\:
Aminosalicylates (e.g. Mesalazine)\:
Corticosteroids (e.g. Prednisolone)\: induce remission during relapses.
Thiopurines (e.g. Azathioprine)\: steroid-sparing, induce/maintain remission.
Biologics (e.g. In
Surgical (for refractory UC or complications)\:
Subtotal colectomy\: part of colon resected, temporary ileostomy.
Complete proctocolectomy\: entire colon and rectum resected, permanent ileostomy.
Restorative proctocolectomy\: entire colon and rectum resected, temporary ileostomy, later ileal pouch-anal anastomosis
(IPAA).
Complications\: severe bleeding, bowel perforation, toxic megacolon, malnutrition, venous thromboembolism,
osteoporosis, colorectal cancer (increased risk with long history of UC, necessitates colonoscopic surveillance).
Article 🔍
A comprehensive topic overview
https\://app.geekymedics.com/notebook/2624/ 1/611/14/24, 10\:39 AM Ulcerative Colitis

Introduction

Ulcerative colitis (UC) is a chronic, relapsing-remitting, in
the most common form of in
in
1
Although UC can be diagnosed at any age, its’ incidence is often described as being bimodal (15-30 years and 50-70
years).
2

Anatomy and pathophysiology

The exact underlying aetiology of UC remains unclear, however, there is some evidence that the combination of an altered
intestinal microbiota and compromised colonic epithelial integrity, results in the inappropriate exposure of non-sterile
intestinal contents to the underlying immunological tissue causing in
factors have all been suggested to have an important role in disease pathogenesis.
3

Risk factors

Important risk factors for UC include\:
4
Family history of IBD
HLA-B27 positive
Recent gastrointestinal infection
NSAIDs
Smoking cessation (overall bene
Ashkenazi Jewish descent

Clinical features

History

Typical symptoms of UC include\:
3
Diarrhoea ± blood ± mucus
Urgency
Tenesmus
Lower abdominal pain
Abdominal discomfort and bloating
Fatigue
Weight loss
Malaise
Other symptoms may relate to extra-intestinal manifestations of UC\:
5
Ophthalmic symptoms\: iritis, uveitis, episcleritis
Dermatological symptoms\: erythema nodosum, pyoderma gangrenosum
Musculoskeletal symptoms\: arthritis (both large and small joints may be a
Hepatobiliary symptoms\: gallstones, primary sclerosing cholangitis (PSC)
Renal symptoms\: nephrolithiasis
Haematological symptoms\: anaemia, thromboembolism

Clinical examination

Typical abdominal examination may include\:
Lower abdominal pain
Lower abdominal tenderness
https\://app.geekymedics.com/notebook/2624/ 2/611/14/24, 10\:39 AM Ulcerative Colitis
Abdominal distension
A digital rectal examination (DRE) may also be necessary to screen for the presence of blood suggesting anorectal
pathology.
Other
Features of anaemia (e.g. pallor, fatigue)
Joint pain
Clubbing
Erythema nodosum
Pyoderma gangrenosum
Uveitis
Episcleritis

Classi

Di
6
Proctitis\: rectum
Proctosigmoiditis\: rectum and sigmoid colon
Left-sided colitis\: rectum, sigmoid colon and descending colon
Extensive colitis\: rectum, sigmoid colon, descending colon and transverse colon
Pancolitis\: rectum and entire colon
UC can also be classiTruelove and Witts criteria.

Di

Other diagnoses with similar clinical features that are important to consider include\:
4
Infectious colitis
Crohn’s disease
Ischaemic colitis
Radiation colitis
Diverticulitis
Vasculitis
Irritable bowel syndrome (IBS)\: this is an important diagnosis of exclusion

Investigations

A diagnosis of UC is predominantly made based on features of the clinical history and endoscopic
important that other causes of colitis and diarrhoea, both infectious and non-infectious, are ruled out before a diagnosis of
UC is made.

Laboratory investigations

Blood tests
7
Blood tests relevant to the investigation of UC include\:
FBC\: anaemia, raised WCC
U&Es
CRP\: elevated
LFTs\: hypoalbuminaemia (severe disease)
pANCA (if PSC is suspected)
Stool tests
https\://app.geekymedics.com/notebook/2624/ 3/611/14/24, 10\:39 AM Ulcerative Colitis
Stool tests relevant to the investigation of UC include\:
Faecal calprotectin is signi
between IBS and IBD)
Microscopy and culture\: important for the exclusion of infection (e.g. S a l m o n e l l a , E .c o l i , C a m p y l o b a c t e r )

Imaging

Endoscopy is the gold standard investigation for the diagnosis of UC.
4
Sigmoidoscopy ± colonoscopy (and biopsy)
A
if
of bowel perforation.
Macroscopic
Continuous, uniformly in
Erythematous, friable mucosa
Abnormal vascular pattern
Ulceration
In
Microscopic
Crypt abscesses
Decreased goblet cell abundance
Additional imaging modalities
Additional imaging modalities such as plain abdominal X-ray (AXR) and computed tomography (CT) may be important for
the exclusion of UC complications in an acute presentation (e.g. toxic megacolon, bowel perforation).

Management

The two main aspects of management include the induction of remission and maintenance of remission.
Most patients are managed with optimal medical therapy which is escalated in a stepwise fashion, dependent on disease
severity and symptom control. However, severe disease and uncontrollable
intervention.
Treatment should be tailored to individuals, based on the severity and extent of disease, with the ultimate aim of improving
quality of life and minimising the risk of complications.
Medical management8
Aminosalicylates (e.g. Mesalazine)
Mesalazine-5-aminosalicylic (5-ASA) is the current
of mild-to-moderate ulcerative colitis.
There are both topical and oral preparations which can be used simultaneously if required.
Corticosteroids (e.g. Prednisolone)
Corticosteroids are typically used to induce remission in relapses of ulcerative colitis.
Unlike 5-ASA, corticosteroids are not used to maintain remission.
Thiopurines
Thiopurines (e.g. Azathioprine) are typically used as a steroid-sparing therapy (e.g. to reduce steroid-related side e
induce and maintain remission.
Before azathioprine treatment, patients must have thiopurine methyltransferase (TPMT) activity checked, as reduced or
absent activity increases the risk of myelosuppression.
Biologics
Biological therapies are typically used when UC is refractory to other treatments.
https\://app.geekymedics.com/notebook/2624/ 4/611/14/24, 10\:39 AM Ulcerative Colitis
Some examples of biologics used in the treatment of UC include\:
Anti-TNFa (e.g. In
Anti-IL-12/23 (e.g. Ustekinumab)
Anti a b (e.g. Vedolizumab)
4 7
Surgical management2
Surgery is predominantly reserved for patients in whom UC cannot be adequately controlled by optimal medical treatment
or upon the occurrence of severe complications (e.g. toxic megacolon, bowel perforation).
Subtotal colectomy
Subtotal colectomy involves resection of part of the colon. Patients are likely to have a temporary de-functioning loop
ileostomy, which can later be reversed, in order to protect the site of anastomosis.
Complete proctocolectomy
Complete proctocolectomy involves the resection of the entire colon and rectum. Patients do not undergo further
anastomotic surgery and thus have a permanent ileostomy.
Restorative proctocolectomy
Restorative proctocolectomy involves resection of the entire colon and rectum and a temporary loop ileostomy, which is
later reversed with further surgery involving the joining of the ileal pouch to the anal canal (ileal pouch-anal anastomosis,
IPAA).
Complete proctocolectomy with IPAA is the procedure of choice.

Complications

Untreated or poorly managed UC can result in various complications, including\:
4
Severe bleeding
Bowel perforation
Toxic megacolon
Malnutrition
Venous thromboembolism
Osteoporosis
Colorectal cancer\: Individuals with a long history of UC are o
of malignancy. Frequency of surveillance is dependent on individual patient risk (low, intermediate, high).

References

Guan Q. A C o m p r e h e n s i v e R e v i e w a n d U p d a t e o n t h e P a t h o ge n e s i s o f I n [LINK]
Journal of Immunology
Ordás I, Eckmann L, Talamini M, Baumgart D and Sandborn W. U l c e r a t i v e c o l i t i s. Lancet. Published in 2012. Available from\:
[LINK]
Danese S and Fiocchi C. U l c e r a t i v e C o l i t i s . New England Journal of Medicine. Published in 2011. Available from\: [LINK]
BMJ Best Practice\: U l c e r a t i v e c o l i t i s - S y m p t o m s , d i a g n o s i s a n d t r e a t m e n t . Published in 2019. Available from\: [LINK]
Levine J and Burako
Hepatology. Published in 2011. Available from\: [LINK]
Ghosh S, Shand A, and Ferguson A. U l c e r a t i v e c o l i t i s . BMJ. Published in 2000. Available from\: [LINK]
Adams S and Bornemann P. U l c e r a t i v e c o l i t i s . American Family Physician. Published in 2013. Available from\: [LINK]
Chudy-Onwugaje K, Christian K, Farraye F, and Cross R. A S t a t e-o f -t h e-A r t R e v i e w o f N e w a n d E m e r g i n g T h e r a p i e s f o r t h e
T r e a t m e n t o f I B D . In[LINK]
https\://app.geekymedics.com/notebook/2624/ 5/611/14/24, 10\:39 AM Ulcerative Colitis

Reviewer

Dr Elspeth Alstead
Consultant Gastroenterologist

Related notes

Acute Pancreatitis
Barrett’s Oesophagus
Coeliac Disease
Crohn's Disease
Hyperlipidaemia

Test yourself

Contents

Introduction
Anatomy and pathophysiology
Risk factors
Clinical features
Classi
Di
Source\: geekymedics.com
https\://app.geekymedics.com/notebook/2624/ 6/6