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| Ulcerative Colitis, My Gastro room blog |
Incidence 10-20 / 100000 , more women
1 parent with UC, 6 % chance chlid with CD
If both parents have IBD, 30 % chance of the disease by 30 years
Macroscopic features:
- Loss of vasulature
- Confluent inflammation form anal verge
- Odema, granularity and ulceration
- Purulent exudate
- pseudopolyps
Histology:
- Crypt abscesses
- Crypt shorening and brnaching and distortion
- Goblet cell depletion
- Inflammatory cell infitrate in the lamina propria
- Liver is affected in 5% of patients (primary sclerosing cholangitis and autoimmune liver disease),
- Joints in 20% (seronegative arthritis of the large joints, sacroiliitis, and ankylosing spondylitis),
- Eye in around 5% (scleritis, episcleritis, and anterior uveitis),
- Skin in 5% (erythema nodosum and pyoderma gangrenosum).
The exact pathophysiology is unknown, but the condition is probably caused by an inappropriate immune response to an unknown environmental stimulus within the colon.
The diagnosis is secured if inflammation of the colorectum is confirmed and colorectal epithelial biopsies show chronic changes, including crypt distortion, along with acute inflammatory changes of cryptitis, crypt abscesses, and a plasma-lymphocytoid cell infiltrate in the lamina propria.
Ulcerative colitis is a chronic lifelong disorder.
One in five patients will require sickness related absence from work or school, which impacts adversely on quality of life.
About 50% of affected people are in remission at any one time, but 90% will experience a relapsing and remitting course.
Mild to moderate flares of disease activity are often treated with oral or topical 5-aminosalicylates or oral glucocorticosteroids. These drugs inhibit production of cytokines and other inflammatory mediators, although the exact mechanisms underlying their beneficial effects in ulcerative colitis are unknown.
Glucocorticosteroids usually act within days, whereas 5-aminosalicylates may take up to four weeks to have any benefit. If there is no response to 5-aminosalicylates within two weeks, consider switching to oral glucocorticosteroids.
Some patients with difficult to control disease may benefit from combined oral and topical 5-aminosalicylates.
Severe exacerbations, characterised by the passage of at least six bloody stools a day (often with nocturnal symptoms), with systemic signs, anaemia, or raised inflammatory markers usually require admission to hospital for intravenous glucocorticosteroids.
Azathioprine, and its metabolite mercaptopurine, are the most commonly used immunosuppressants in ulcerative colitis. They are usually used in an attempt to maintain glucocorticosteroid induced remission, where 5-aminosalicylates have failed. Despite their widespread use, the evidence base to support their efficacy is not strong.
A meta-analysis of all five RCTs found a significant effect of infliximab over placebo in moderately to severely active disease.In the United Kingdom, the use of infliximab is restricted to three dose induction therapy for acute severe exacerbations.
More recent RCTs, that enrolled similarly refractory outpatient populations, have shown that adalimumab is significantly superior to placebo, although absolute differences in remission rates were modest (7-9%).The meta-analysis of RCTs of infliximab found no significant difference in adverse event rates.
Colectomy is an option for patients who do not respond to, or are intolerant of, medical treatment, or in those with complications such as colorectal neoplasia.
Extra-intestinal manifestations occur in patients with both Crohn’s disease (particularly with colonic CD) and UC.
ReplyDeleteSome are related to disease activity:
arthritis symmetrically affecting medium-sized joints
ocular problems like episcleritis, iritis and uveitis
erythema nodosum - painful, raised, red lesions typically on the shins
aphthous ulcers
finger clubbing
pyoderma gangrenosum (less than 5%) - typically a single lesion affecting the lower limb which develops into a deep ulcer with a necrotic base and undermined purple edges with a purulent sterile discharge
Some are unrelated to disease activity:
gallstones
sacroiliitis
liver disease - fatty changes and primary sclerosing cholangitis (more common in UC)
renal stones and ureteric strictures
osteomalacia
nutritional deficiency
systemic amyloid
A patient with UC taking 6-MP for five years experiences a flare and is started on prednisone. He responds initially, but then begins to flare on tapering of the steroids. Stool study results are negative. On sigmoidoscopy, deep ulcers are seen. Which of the following is the next best step in the management of this patient?
ReplyDelete1-start IFX
2-start cyclosporin
3-Bx from ulcer and surrounding
4-increase 6MP
5-colectomy
n patients with UC taking immunosuppressants and/or glucocorticosteroids, especially those with long-standing disease, the diagnosis of cytomegalovirus must be included in the differential diagnosis. On endoscopy, discrete deep ulcers may be seen, although inflammatory changes resembling UC can also be found. Biopsies of the ulcer bed and surrounding mucosa must be performed in the appropriate setting to look for giant cells with inclusion bodies. If there is no evidence of cytomegalovirus, then initiation of infliximab or cyclosporine might be appropriate. Increasing or optimizing the dose of 6-MP may be an option, but can take two to three months to have a clinical effect. Colectomy might be necessitated if the patient is either too sick to withstand further medical therapy or it is ineffective.
EIMs of UC often parallel colonic disease activity. Various musculoskeletal abnormalities are seen with UC, including arthropathies.
ReplyDeleteThese are divided into both axial arthropathies, encompassing both sacroiliitis and ankylosing spondylitis, with the latter often being HLA-B27 positive. Sacroiliitis is more common, seen in 10% to 15% of UC patients, and patients either are asymptomatic or have mild low back pain; ankylosing spondylitis is seen in only 1% to 2% and may manifest with more severe symptoms and radiographic changes.
Ocular EIMs include episcleritis and uveitis, with the former paralleling intestinal symptoms and the latter less predictably so. Episcleritis is seen in 5% to 8% of patients and presents with hyperemia of the conjunctiva and sclerae but is not painful and does not result in vision compromise.
Uveitis, on the other hand, manifests with eye pain and blurry vision; immediate ophthalmologic examination and ocular glucocorticosteroid eyedrops are warranted.
Erythema nodosum is one of the dermatologic manifestations that may be seen with UC; it usually parallels intestinal activity of UC. It occurs in 2% to 4% of patients and manifests with tender, raised erythematous nodules usually on the extensor surfaces of the lower extremities; biopsies should be avoided as scarring may be worse. Erythema nodosum usually remits with treatment of the underlying UC. Aphthous ulcerations of the mouth will be seen in approximately 10% of patients and generally occur simultaneously with colitis flares.
EIM parallel to IBD activity:
ReplyDeleteErythema nodosum
Oral aphthoid ulcers
Prepheral arthritis
Episcleritis
EIM independent of IBD activity:
Ankylosing spodylitis
PSC
Pyoderma gangrinosum
Scleritis
The most important risk factors for colorectal cancer in UC are duration and extent of disease. In general, the risk is estimated to increase at a rate of 0.5% to 1% per year after eight to 10 years of disease in patients with extensive colitis. The risk of colorectal cancer is approximately 7% to 10% at 20 years and as high as 35% after 30 years. Primary sclerosing cholangitis, a chronic inflammatory disease of the biliary tree that progresses to fibrosis, cirrhosis, and end-stage liver disease, is seen in approximately 3% of patients with UC. These patients are at a significantly higher risk of colorectal cancer than those without it and need to begin surveillance immediately after diagnosis of primary sclerosing cholangitis. Other risk factors for colorectal cancer in UC include severity of inflammation, family history of colorectal cancer, age at diagnosis, smoking, and the presence of pseudopolyps (not explicitly stated in the chapter). Surveillance colonoscopy generally every one to two years should begin between eight and 10 years after symptom onset in those patients with disease beyond the rectum. Surveillance colonoscopy ideally should be done when patients are clinically in remission and four-quadrant biopsies should be performed every 10 cm with targeted biopsies obtained from any raised or suspicious-appearing lesions. At least 33 biopsies are required to achieve a 90% probability of identifying dysplasia, and 64 biopsies for a probability of 95%. Chromoendoscopy, high-magnification endoscopy, and narrow-band imaging may increase the yield of dysplasia detection but are not yet part of the standard of care.
ReplyDeleteQ:A 29-year-old man experiences abdominal pain and bloody diarrhea for one week. Initial stool examination shows red and white cells. A sigmoidoscopy reveals erythema and erosions diffusely, and the biopsy sample shows an inflammatory infiltrate in the lamina propria with distortion and branching of the glands. What is the most likely diagnosis?
ReplyDelete1-UC
2-Campylobacter jejuni infection
3-Salmonellosis
4-Aeromonas infection
5-Enterohemorrhagic E. coli
1 correct
The key is the branching and distortion of the gland architecture. This only occurs in chronic colitis. In acute colitis due to an infection, the architecture of the glands is not distorted and branching does not occur. The first episode of UC can be mistaken for acute infectious colitis, but a biopsy can usually distinguish the two. A photomicrograph of an acute colitis is pictured
I was diagnosed as HEPATITIS B carrier in 2013 with fibrosis of the
ReplyDeleteliver already present. I started on antiviral medications which
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