intro,pathophysiology,clinical features,investigations ,management

1. ULCERATIVE COLITIS
Dr Raman Ghimire

2. OUTLINES
 Introduction
 Epidemiology
 Pathophysiology
 Types
 Clinical Features
 Investigations
 Severity index
 Management
NICE guidelines
 MCQs

3. INTRODUCTION
 Inflammatory bowel disease(IBD):
Group of idiopathic chronic inflammatory disease of GIT consisting of two distinct
clinical entities
1. Ulcerative colitis (UC)
2. Crohn’s disease (CD)/Regional enteritis
 UC is the most common form of inflammatory bowel disease worldwide
 UC is an idiopathic, chronic inflammatory disorder of the colonic mucosa that commonly
involves the rectum and may extend in a proximal and continuous fashion to involve
other parts of the colon.
 UC is characterized by a relapsing and remitting course.

4. EPIDEMIOLOGY
 INCIDENCE: 9 to 20 cases per 100,000 persons per year
 Bimodal pattern of incidence ;
main onset peak :15 -30 years
second small peak :50 -70 year
 Sex: male = female
 More common in developed nations
 Jewish people

5. PATHOPHYSIOLOGY
 RISK FACTORS
 Genetic predisposition: family history
 Altered, dysregulated immune response
 Altered response to gut microorganisms
 Low antioxidants
 OCP
 Stress
 TRIGGERING EVENTS
 Recent smoking cessation
 NSAID use
 Enteric infections
(particularly C. difficale)
 PROTECTIVE FACTORS
 Appendectomy
 Smoking

8. COMPLICATIONS
 ACUTE
 Hemorrhage
 Toxic megacolon
 Perforation
 CHRONIC
 Stricture
 CA colon
 Extracolonic manifestations

9. CLINICAL FEATURES
A.SYMPTOMS
 bloody diarrhea, with or without mucus
 urgency or tenesmus
 abdominal pain
 malaise
 weight loss
 fever

10. B. PHYSICAL FINDINGS
 Tachycardia
 Raised temperature
 Significant abdominal tenderness
 Weight loss
 Dehydration
 Pallor

11. EXTRAINTESTINAL MANIFESTATIONS(EIM)
 EIM dependent of disease activity
 Episcleritis, scleritis
 Mouth ulcers
 Peripheral arthropathies (4-20%)
 Erythema nodosum (10-20 %)
 EIM independent of disease activity
 Uveitis
 Axial arthropathies (3-10%)
 Sacroiliitis
 Ankylosing spondylitis
 Autoimmune hepatitis
 EIM may or may not dependent of
disease activity
 Pyoderma gangrenosum
 Primary sclerosing cholangitis (PSC)
Erythema Nodosum Pyoderma gangrenosum

12. INVESTIGATIONS
 Raised ESR,CRP & leukocytosis
 Perinuclear antineutrophil cytoplasmic antibodies (P-ANCA): 60% to 70%
 Anti-saccharomyces cerevisiae antibodies (ASCA) may be positive but are more prevalent in
Crohn disease
 carcinoembryonic antigen (CEA) ; higher levels can indicate a flare.
 Fecal calprotectin : nonspecific. correlates with increased neutrophils in the intestine
 Stool analysis : RME, Ova,cysts,c/s , C.difficale titre
 Serum albumin,electrolytes ,Hb

13. Colonoscopy and Biopsy
 Gold standard for diagnosis
 Colonoscopy Findings :
 Loss of vascular pattern
 Granular and fragile mucosa
 Ulceration, erosions, and/or pseudopolyposis

14.  HPE findings :
 infiltration of the mucosa and submucosa with neutrophils and crypt abscesses
 shortening and branching of the crypts
CRYPT’S ABSCESS
marked lymphocytic infiltration (blue/purple)
architectural distortion of the crypts.

15. IMAGING
 PLAIN X-RAY ABDOMEN
 BARIUM STUDY
 USG
 CT
 MRI
 RADIONUCLIDE STUDY

16. Truelove and Witts’ severity index

17. MANAGEMENT
 Based on extent and the severity of the disease
 GOALS:
 inducing remission
 maintaining remission
 restoring and maintaining nutrition
1.MEDICAL MANAGEMENT
2.SURGICAL MANAGEMENT

18. MEDICAL MANAGEMENT
 AMINOSALICYLATES: sulfasalazine,mesalamine (5-ASA) {topical /oral}
 STEROIDS : Hydrocortisone , Prednisolone, Budesonide(rectal)
 IMMUNOSUPPRESSIVE AGENTS: Azathiprine ,Cyclosporine,6-MP,Tacrolimus
 TNF-INHIBITORS : Infliximab,Adalimubab ,Golimubab
 Janus kinase (JAK) pathway inhibitors: Tofacitinib
 Alpha 4 Integrin Inhibitors : Vedolizumb
 ANTIMICROBIALS: Ciprofloxacin ,Metronidazole
 ANTIDIARRHEAL: Loperamide, Dihenoxylate

21. SURGICAL MANAGEMENT
 Colectomy is curative in patients with ulcerative colitis since the disease is restricted to the colon.
 Indications for surgery:
 failure of medical therapy,
 intractable fulminant colitis,
 toxic megacolon,
 perforation
 uncontrollable bleeding
 intolerable side effects of medications,
 strictures, unresectable high-grade or multifocal dysplasia, cancer

22.  The procedure of choice is proctocolectomy with ileal pouch-anal anastomosis (IPAA)
 Alternative: proctocolectomy with end ileostomy

24. MCQS
 Most common site for Ulcerative Colitis
A. Anal canal
B. Rectum
C. Transverse colon
D. Sigmoid colon
ANS: Rectum (>95%)

25.  NOT a feature of UC
A. p-ANCA +ve
B. Risk of CA colon
C. Bleeding
D. Skip lesion
ANS: Skip lesion
f/o crohns disease , continuous lesion in UC

26. REFERENCES
 Ulcerative colitis management ;NICE guideline [NG130]
 Ulcerative colitis Ingrid Ordás, Lars Eckmann, Mark Talamini, Daniel C Baumgart,
William J Sandborn Lancet 2012; 380: 1606–19
 New developments in ulcerative colitis: latest evidence on management, treatment,
and maintenance: Kartikeya Tripathi, MD and Joseph D Feuerstein, MD
 Uptodate

27. THANK YOU