Related Subjects:
|Achalasia
|Oesophageal Carcinoma
|Diffuse Oesophageal spasm
|Diffuse Oesophageal Perforation - Rupture
|Gastro-Oesophageal Reflux
|Barrett's oesophagus
|Zollinger Ellison syndrome
|Gastrinoma
|VIPomas
|Carcinoid Tumour Syndrome
|Familial Adenomatous polyposis (FAP)
|Colorectal cancer
|Colorectal polyps
|Ulcerative Colitis
|Acute Severe Colitis
|Crohn's disease
|Coeliac disease
|Dermatitis Herpetiformis
🔥 Ulcerative colitis (UC) = a relapsing-remitting inflammatory disease of the colon, starting in the rectum and spreading continuously.
⚠️ Risks: acute severe colitis (medical emergency) + ↑ risk of colorectal cancer.
📖 Overview
- Chronic inflammatory bowel disease (IBD) limited to colon & rectum.
- Incidence ~10–20/100,000; prevalence 50–100/100,000. More common than Crohn’s.
- Peak onset 20–40 years; higher prevalence in Caucasian & Jewish populations.
🧬 Pathophysiology & Etiology
- Dysregulated immune response to gut microbiota in genetically susceptible individuals.
- ⚡ Protective factors: smoking & prior appendicectomy.
- Autoantibodies: pANCA often positive.
- Association: Primary Sclerosing Cholangitis (PSC).
- Mucosal-only inflammation; continuous from rectum → proximal colon.
🩺 Clinical Features
- 💩 Bloody diarrhoea ± mucus; urgency, tenesmus, incontinence.
- 🤒 Systemic symptoms in severe disease: fever, tachycardia, weight loss.
- ⚡ Flare triggers: infections, NSAIDs, antibiotics, stress.
- Extra-intestinal: skin (erythema nodosum, pyoderma gangrenosum), eyes (iritis, episcleritis), joints (arthritis, sacroiliitis), liver (PSC), mouth ulcers, clubbing, ↑ VTE risk.
📊 Severity Assessment (Modified Truelove & Witts)
| Severity | Features |
|---|
| 🙂 Mild | <4 bloody stools/day; no systemic upset; Hb >115; CRP <5 |
| 😐 Moderate | 4–6 stools/day; mild systemic disturbance; Hb >105; CRP <30 |
| 😟 Severe | >6 bloody stools/day + systemic features (T >37.8°C, HR >90, Hb <105, CRP >30) |
| 🚨 Fulminant | ≥10 stools/day, continuous bleeding, severe toxicity, colonic dilatation on AXR |
🔎 Investigations
- 🩸 Bloods: FBC, CRP/ESR, U&E, LFTs, pANCA.
- 💩 Faecal calprotectin: marker of active inflammation.
- 📷 Imaging: AXR (toxic megacolon), sigmoidoscopy (preferred in flare), colonoscopy (extent, surveillance), avoid full colonoscopy in acute flare.
💊 Drug Management (NICE NG130)
| Drug Class | Examples / Dose | Indication / Notes |
|---|
| 5-ASA 🟢 |
Oral Mesalazine 2–4 g/day; Sulfasalazine 2–4 g/day; Rectal 5-ASA enemas 1 g/night |
Mild–moderate UC; combine oral + rectal for extensive disease; monitor renal function |
| Topical steroids 💠 |
Budesonide MMX 9 mg OD; Hydrocortisone enemas 100 mg/day |
Mild–moderate distal colitis; fewer systemic effects |
| Oral corticosteroids 🌟 |
Prednisolone 40–60 mg OD, taper 8–12 weeks |
Moderate–severe flare; monitor BP, glucose, infection risk, bone health |
| IV corticosteroids 🚑 |
Hydrocortisone 100 mg QDS; Methylprednisolone 60 mg OD |
Acute severe UC; assess response at 3–5 days → rescue therapy if refractory; supportive care essential |
| Immunomodulators 🛡️ |
Azathioprine 2–2.5 mg/kg/day; 6-Mercaptopurine 1–1.5 mg/kg/day |
Maintenance/steroid-sparing; monitor FBC/LFTs; check TPMT activity before starting |
| Biologics / Anti-TNF 💉 |
Infliximab 5 mg/kg IV; Adalimumab SC; Vedolizumab 300 mg IV |
Moderate–severe UC unresponsive to steroids/immunomodulators; screen TB/HBV; monitor response via CRP/fecal calprotectin |
| Ciclosporin IV ⚡ |
2 mg/kg/day IV → oral 5 mg/kg/day |
Rescue therapy for steroid-refractory acute severe UC; bridge to azathioprine; monitor BP, renal function |
| Supportive 🧩 |
LMWH prophylaxis, antibiotics if infection, nutritional support |
Reduces complications, optimises outcomes |
🚨 Acute Severe UC (NICE-compliant)
- Admit → IV fluids, IV hydrocortisone, nutritional support, VTE prophylaxis.
- Monitor stool frequency, vitals, bloods, daily AXR.
- No improvement at 3–5 days → rescue therapy (IV ciclosporin or infliximab) or colectomy.
- Toxic megacolon → urgent surgery (subtotal colectomy).
🔪 Surgical Options
- Panproctocolectomy + ileal pouch-anal anastomosis → curative, reduces cancer risk, but ↑ stool frequency, pouchitis risk.
🌱 Supportive & MDT Care
- Dietitian → optimise nutrition.
- IBD nurse specialist → flare management, medication counselling.
- Psychological support if chronic disease impact.
💡 Teaching Pearls
- UC = continuous mucosal inflammation starting at rectum (vs Crohn = skip lesions, transmural).
- Acute severe colitis = medical emergency; IV steroids first, rescue biologics or colectomy if refractory.
- Long-term risk: colorectal cancer → start surveillance after 8–10 years of disease.
- Extra-intestinal features often parallel disease activity.
- Step-up therapy mnemonic: 5-ASA → steroids → immunomodulator → biologics → surgery 🔄
Cases
- Mild–moderate flare 👨🦱: 27-year-old man, bloody diarrhoea 6 weeks. Management: oral + rectal mesalazine, steroids if needed. Outcome: good response.
- Severe acute colitis ⚡: 34-year-old woman, >10 bloody stools/day, fever, tachycardia, CRP 110. Management: admit, IV hydrocortisone, fluids, LMWH, rescue infliximab at 72h if no improvement. Outcome: improved, discharged on oral steroids + azathioprine.
- Toxic megacolon 🚨: 45-year-old man, pancolitis, distension, shock. AXR: transverse colon >6 cm. Management: resuscitation, IV steroids, antibiotics, urgent subtotal colectomy. Outcome: recovered, later pouch surgery.
References 📚
