1. What do these people all have in common?
Stewart Lee - comedian
Sir Steve Redgrave – Olympic rower
William Wilberforce – abolition of the slave trade

2. Ulcerative Colitis

3. Epidemiology Most common IBD Incidence = 10 in 100 000
Prevalence = 240 per
Age of onset
Peak incidence: years
Second smaller peak years
M=F

4. Aetiology UNKNOWN - ?autoimmune Risk factors: Smoking – protective
Genetics – FHx of UC or CD
Developed countries
Ethnicity – Caucasian (Northern Europe and America)
Smoking – protective

5. Pathogenesis Genetically susceptible host – MDR1 gene variants
Increased immune response to enteric commensal bacteria
Innate immune system – macrophages, neutrophils
Acquired immune system – T cells, B cells
Release of inflammatory cytokines
Environmental factors – stress, infection, NSAIDs

6. Symptoms Bloody, mucoid diarrhoea/rectal bleeding
Colicky abdominal pain
Urgency
Tenesmus
Constipation
Weight loss
Malaise
Extra-intestinal symptoms:
Joints – sacroiliitis, ankylosing spondylitis
Skin – pyoderma gangrenosum, erythema nodosum
Eyes – anterior uveitis

7. Signs Guarding on abdominal palpation Thin, pale Tachycardia Pyrexia
Signs of anaemia

8. Diagnosis
Stool sample - raised faecal calprotectin = suggestive of colonic inflammation
Bloods - raised ESR/CRP, anaemia
AXR (rule out toxic megacolon)
Colonoscopy with multiple biopsies
Continuous inflammation of mucosa from rectum
Only in the colon (vs CD) – may be backwash ileitis
No skip lesions, granulomas, deep ulcers, strictures, fissures or fistulas

9. Treatment Aminosalicylates – mesalazine (topical and/or oral)
Induction and maintenance of remission
Corticosteroids – prednisolone (topical or oral)
Induction of remission (relapse, severe)
Thiopurines – azathioprine
Corticosteroid intolerance/regular relapses
Surgery – colectomy in 30%
Unresponsive to treatment, complications (toxic megacolon, colorectal neoplasia)

10. Prognosis Relapsing-remitting course, variable
Social stigma of colostomy bag, using disabled toilets
2x increased risk of colorectal cancer
Surveillance colonoscopy after 10 years of disease, every 1-5 years dependent on risk
Colectomy for high-grade dysplasia

11. Case study 15 year old male
Reports frequently passing stool with abdominal discomfort
What else should you ask?

12. Case study How many times a day?
Any blood? Every time or just sometimes? Fresh/mixed in?
Mucus?
Associated nausea/vomiting?
Recent travel?
Food triggers?
Weight loss?
Mouth ulcers? Rectal fissures?
Extra-intestinal symptoms?

13. Case study Investigations: Management:
Bloods – FBC, CRP/ESR, U&E, LFT, coeliac screen (tTG)
Stool sample – faecal calprotectin, culture (OCP)
Imaging – AXR, ?CT/MRI
Endoscopy – colonoscopy with biopsy
Management:
Induce remission – mesalazine +/- prednisolone
Maintain remission – mesalazine
Monitor regularly, recognition of relapse

14. MCQ What is the peak age of onset of ulcerative colitis? 5-15 15-25
25-35
35-45

15. MCQ Which of the following is NOT a risk factor for developing UC?
Gastrointestinal infection
MDR-1 gene variation
Stress
Smoking

16. MCQ Which of the following may be a sign of UC? Pale stools Vomiting
Weight loss
Bradycardia

17. MCQ
Which of the following is first-line treatment for induction of remission in UC?
Azathioprine
Mesalazine
Mercaptopurine
Budesonide

18. MCQ What is the peak age of onset of ulcerative colitis? 5-15 15-25
25-35
35-45

19. MCQ Which of the following is NOT a risk factor for developing UC?
Gastrointestinal infection
MDR1 gene variation
Stress
Smoking

20. MCQ Which of the following may be a sign of UC? Pale stools Vomiting
Weight loss
Bradycardia

21. MCQ
Which of the following is first-line treatment for induction of remission in UC?
Azathioprine
Mesalazine
Mercaptopurine
Budesonide

22. Summary Most common type of IBD Multifactorial aetiology
Relapsing-remitting course
Bloody diarrhoea/rectal bleeding = most common symptom
Diagnosis = colonoscopy with biopsies
Treatment:
Remission with mesalazine +/- prednisolone
Maintenance with mesalazine
Increased risk of colon cancer and toxic megacolon -> colectomy

23. SUMMARY

24. SUMMARY: UC Vs. Crohn’s? CROHN’S DISEASE ULCERATIVE COLITIS ORIGIN
Terminal ileum
Rectum
PROGRESSION PATTERN
Skip lesions, irregular
Proximally contiguous
INFLAMMATION
Transmural
Submucosa or mucosa
SYMPTOMS
Crampy Abdominal pain
BLOODY DIAHRRHEA
COMPLICATIONS
Fistulas, obstruction, abscess
Toxic megacolon, Hemorrhage
RADIOGRAPHS
String Sign: Barium X-ray
Lead pipe colon: Barium X-ray
SURGERY
Certain complications (Strictures)
Can be CURATIVE
SMOKING
HIGHER RISK
LOWER RISK
COLON CANCER RISK?
SLIGHT Increase
MARKED Increase

25. IBS Vs. IBD

26. Thank you! Any questions?

27. References
Ulcerative Colitis -
Mechanisms of Disease: Pathogenesis of Crohn's Disease and Ulcerative Colitis -
Pathology Outlines -
NHS choices -
NICE guidelines for UC - node%3Anodes-step-1-therapy-left-sided-and-extensive-ulcerative- colitis&path=view%3A/pathways/ulcerative-colitis/inducing-remission-in-people-with-ulcerative- colitis.xml