Department level talk on Ulcerative Colitis

1. ULCERATIVE COLITIS
DR. ABUBAKKAR RAHEEL
SHO – GASTROENTEROLOGY
UNIVERSITY HOSPITALS OF LEICESTER, NHS

2. CASE PRESENTATION
• 22 years old female was admitted to the Ward 42 in February 2019 following frequent episodes of bloody
diarrhea and left sided abdominal pain
• Bowel frequency was 2-3 times a day, pre-admission
• She had a background of Ulcerative colitis diagnosed in 2012 at the age of 16
• Her treatment history included mesalazine, oral prednisolone and 6-mercaptopurine. In 2015 she was switched
to methotrexate which was continued until October 2018. She only reported one hospital in-patient admission in
2012.
• She did not report any history of smoking or drinking.
• Her medical record contained history of chronic iron deficiency anaemia

3. IN-PATIENT MANAGEMENT
• Bowel frequency increased to 4-5 times per day.
• Bowels were type-6 mixed with blood and mucus.
• On examination, she had tenderness over left quadrant of the abdomen on deep palpation.
• Her abdominal x ray demonstrated faecal loading on the left side but no toxic megacolon
• Her bloods showed a CRP of 24, Hb 67g/dl, WCC 11.4
• She was transfused 2 units of red cells due to low hemoglobin.
• She was subsequently commenced on infliximab due to active flare of the ulcerative colitis
• Surgical option was discussed with her given the severity of her condition and possibility of failure of medical
treatment

4. WHAT IS ULCERATIVE COLITIS ?

5. ULCERATIVE COLITIS
• Ulcerative colitis is a type of inflammatory bowel disease characterised by diffuse inflammation of the colonic
mucosa and a relapsing, remitting course
• Ulcerative colitis is a relapsing and remitting condition of the colonic muscosa which may effect just the rectum
(proctitis) or extend to involve part of the colon (left sided colitis) or the entire colon (pancolitis)
• – Oxford handbook of Clinical Medicine

6. INCIDENCE
• Prevalence: 240/100,000
• Incidence: 10-20/100,000/year
• 146000 people in UK diagnosed with Ulcerative Colitis
• Female : male – 1.5:1
• Average age 15-30 years

7. TYPES

8. SYMPTOMS
• Episodic or chronic diarrhoea
• Crampy abdominal discomfort
• Urgency/tenesmus
• Systemic symptoms
• Fever
• Malaise
• Anorexia
• Weight loss

9. SIGNS
Can vary on severity
• Fever, tachycardia and tender distended abdomen (acute severe UC)
• Clubbing
• Aphthous ulcers
• Erythema nodosum
• Pyoderma gangrenosum
• Conjunctivitis, episcleritis, iritis
• Large joint arthritis, ankylosing spondylitis, sacroiliitis
• Fatty liver, cholangiocarcinoma, amyloidosis

10. INVESTIGATIONS
• Bloods
• FBC, CRP, U&E, LFT, Blood culture, Stool MC&S/CDT
• Abdominal Xray
• Faecal shadowing, mucosal thickening islands
• Erect Chest Xray
• Perforation
• Barium Enema
• Mucosal inflammation, mucosal ulcers
• Endoscopy and biopsy
• Disease activity, Inflammation inflitrate, mucosal ulcers and crypt abscesses

11. HISTOLOGY
• Inflammation restricted to colonic mucosa
• Crypt distortion, shortening and branching crypts (architectural distortion)
• Pseudovellous surface.
• Lymphoplasmocitosis
• Microabscess and cryptitis

12. HISTOLOGY

13. HISTOLOGY

14. ENDOSCOPY
Fig. 1.
Typical endoscopic features of ulcerative colitis. (A) Mild: mucosal erythema, fine
granularity, decreased vascular marking. (B) Moderate: marked erythema, loss of
vascular marking, erosions. (C) Severe: ulcers. (D) Severe: spontaneous bleeding. (E)
Luminal narrowing with pseudopolyps

15. COMPLICATIONS
• Perforation
• Bleeding
• Toxic dilatation of the colon
• Venous thrombosis (give prophylaxis to all)
• Colonic cancer (risk 15% with pancolitis in 20 years)

16. TREATMENT STRATEGY
Treatment
strategy
Clinical
Severity
Extent of
disease
personal
preference

17. TRUELOVE & WITTS CRITERIA
VARIABLE MILD MODERATE SEVERE
Motions/day <4 4-6 >6
Rectal bleeding Small Moderate Large
Temp at 6am apyrexial 37.1-37.8C >37.8C
Resting pulse <70bpm 70-90bpm >90bpm
Hb >110g/l 105-110g/l <105g/l
ESR <30 >30-CRP>45mg/l

18. TREATMENT PARADIGM

19. TREATMENT ALGORITHM

20. TAKE HOME MESSAGE
”Inflammatory Bowel Disease is like riding a rollercoaster – one minute you are up, the next you are down. As
someone with the condition, I understand how tough it can be and how important it is to be able to talk to
an empathetic person at the end of the phone.”

21. Thank you