QuestionSBA
QuestionChoice
Topical aminosalicylates may be used for mild-moderate IBD flares. As this patient has a temperature over 37.8 degrees, they are experiencing a severe flare.
10015707
b
Rectal mesalazine foam
QuestionChoice
The patient is suffering from a severe flare of ulcerative colitis according to the Trulove and Witts critera, as he has a temperature of over 37.8 degrees. Other severe features are tachycardia (>90bpm), >6 bloody stools a day, haemoglobin <105g/L, or an ESR >30mm/h / CRP >30 mg/dL. IV steroids are indicated.
10015706
a
Intravenous corticosteroids
QuestionChoice
Steroids should be administered first, with non-responders progressing to biologic rescue therapy.
10015709
d
Start infliximab
QuestionChoice
This may be required if the patient fails conservative management or has features of perforation.
10015710
e
Pancolectomy
QuestionChoice
Oral antibiotics are not indicated in flares of IBD.
10015708
c
Oral antibiotics
QuestionComment
pyrexia alone doesnt make it severe, need further information to distinguish between rectal mesalazine and iv corticosteroids

36977
QuestionComment
Agreed, temperature alone makes it only a moderate flare - which can be managed with mesalazine 
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Gland Hereditary
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I guess what made me sway towards steroids is the GP referring to ed. If they needed just rectal ASA GP could have prescribed that themselves
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Ale
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Diego
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I got this right
57397
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okay 
62244
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Syndrome Nightshift
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Kat
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# Summary

Ulcerative colitis (UC) is a chronic inflammatory disease that affects the large bowel. Symptoms include diarrhoea, urgency, tenesmus, weight loss, and fever. The disease can present with extra-intestinal features such as dermatological (erythema nodosum), ocular (anterior uveitis), musculoskeletal (finger clubbing), and hepatobiliary manifestations (jaundice due to primary sclerosing cirrhosis). Investigations include blood tests, microbiological investigations, endoscopic investigations, and imaging. The management of UC is based on severity and involves inducing and maintaining remission using medications like aminosalicylates, steroids, and biologics. Surgery may be required in severe cases or when medical treatment is unsuccessful. Long-term complications include colorectal cancer, cholangiocarcinoma and colonic strictures.

# Definition

Ulcerative colitis (UC) is a chronic relapsing-remitting inflammatory disease that primarily affects the large bowel. It usually affects the rectum first, then can extend to the part of the colon (left-hand-side colitis) or the entire colon (pancolitis). It does not spread beyond the ileocaecal valve or to the small bowel, except where backwash ileitis can occur.

# Epidemiology

UC is the most commonly diagnosed inflammatory bowel disease. It has an annual incidence rate of 10 per 100,000 people and a prevalence rate of 243 per 100,000. Although UC can develop at any age, it most frequently occurs in two peak age groups: 15 to 25 years and 55 to 65 years.

# Aetiology

The exact cause of UC is unknown, but it is believed to result from a combination of genetic predisposition, environmental factors, and dysregulation of the immune system. There is also a higher incidence of UC among non-smokers and ex-smokers.

# Signs and Symptoms

The main symptoms of UC are gastrointestinal and systemic. 

Gastrointestinal symptoms include:

- Diarrhoea often containing blood and/or mucus
- Tenesmus or urgency
- Generalised crampy abdominal pain in the left iliac fossa

Systemic symptoms include:

- Weight loss
- Fever
- Malaise
- Anorexia

Physical examination may reveal general signs such as pallor due to anaemia and clubbing. Abdominal examination may reveal distension or tenderness, and a PR examination may show tenderness, and blood/mucus. 


Extra-intestinal signs occur in 10-20% of patients and include:

- Dermatological manifestations: erythema nodosum, pyoderma gangrenosum
- Ocular manifestations: anterior uveitis, episcleritis, conjunctivitis
- Musculoskeletal manifestations: clubbing, non-deforming asymmetrical arthritis, sacroiliitis
- Hepatobiliary manifestations: jaundice due to primary sclerosing cholangitis (PSC). 80% of those with PSC have ulcerative colitis.
- Other features include AA amyloidosis




# Differential Diagnosis

The differential diagnoses for UC include Crohn's disease, infectious colitis, and ischemic colitis. Key signs and symptoms to differentiate these conditions include:

- Crohn's disease: Abdominal pain, weight loss, diarrhea, oral ulcers, anal fissures, and perianal fistulas.
- Infectious colitis: Acute onset of diarrhea, fever, and abdominal pain. May be associated with recent antibiotic use, travel, or consumption of contaminated food or water.
- Ischemic colitis: Sudden onset of abdominal pain, blood in stools, and a history of vascular disease or risk factors.

# Investigations

**Bedside:**

- Microbiological investigations: Stool microscopy (for ova/cysts/parasites), culture and sensitivity, and stool C. difficile toxin to exclude infective colitis
- Faecal calprotectin: Distinguishes between inflammatory bowel syndrome (normal) and inflammatory bowel disease (raised)

**Bloods:**

- Blood tests: FBC (anaemia and a raised white cell count), ESR/CRP is typically raised, LFTs may show a low albumin

**Imaging/Invasive:**

- Radiological investigations: Abdominal X-ray and erect chest x-ray in acute settings to exclude toxic megacolon and perforation.
	- Long-standing UC will show 'lead-pipe' colon on AXR 
- Endoscopic investigations: Colonoscopy, barium enema, and biopsy are used to confirm the diagnosis.
    - Colonoscopy will reveal shows continuous inflammation starting at the rectum that does not go beyond the submucosa with an erythematous mucosa, loss of haustral markings, and pseudopolyps.
    - Biopsy: loss of goblet cells, crypt abscess, and inflammatory cells (predominantly lymphocytes)
    - Barium enema will reveal lead-piping inflammation (secondary to loss of haustral markings), thumb-printing (a marker of bowel wall inflammation), and pseudopolyps (due to areas of ulcerating mucosa adjacent to areas of regenerating mucosa). This is less commonly used nowadays due to the increasing availability of endoscopic investigations

# Truelove and Witt's Criteria for Severity

An acute exacerbation of ulcerative colitis should be assessed using the Truelove and Witt's severity index.

|                                               | **Mild**                            | **Moderate**            | **Severe**                                                                           |
| --------------------------------------------- | ----------------------------------- | ----------------------- | ------------------------------------------------------------------------------------ |
| **Bowel movements (no. per day)**             | Fewer than 4                        | 4-6                     | 6 or more plus at least one of the features of systemic upset (marked with \* below) |
| **Blood in stools**                           | No more than small amounts of blood | Between mild and severe | Visible blood                                                                        |
| **Pyrexia (temperature greater than 37.8°C)** | No                                  | No                      | Yes                                                                                  |
| **Pulse rate greater than 90 bpm**            | No                                  | No                      | Yes                                                                                  |
| **Anaemia (< 10g/100mL)**                     | No                                  | No                      | Yes                                                                                  |
| **Erythrocyte sedimentation rate (mm/hour)**  | 30 or below                         | 30 or below             | above 30                                                                             |


# Management


## Mild-moderate disease

The aim of step 1 treatment is to induce remission. If this does not work after 4 weeks, or symptoms worsen, move to step 2.

The first step in management for a moderate first presentation is to offer a topical aminosalicylate as first-line treatment. If remission is not achieved within 4 weeks, consider adding an oral aminosalicylate. In acute moderate disease if all other measures haven't worked then a trial of Etrasimod (also known as Velsipity). This is a selective sphingosine 1-phosphate (S1P) receptor modulator.

- **Proctitis and proctosigmoiditis:**
  - Step 1: Topical ASA or oral ASA.
  - Step 2: Consider adding oral prednisolone. If this does not help after 2-4 weeks or symptoms worsen, consider adding oral tacrolimus.
- **Left sided or extensive disease**
  - Step 1: High dose oral ASA.
  - Step 2: Consider adding oral prednisolone. If this does not help after 2-4 weeks or symptoms worsen, consider adding oral tacrolimus.

## Acute severe disease

- Step 1: IV corticosteroids (if contraindicated or not tolerated, use IV ciclosporin).
- Step 2: If no improvement in 72 hours or worsening symptoms, add IV ciclosporin or consider surgery (if IV ciclosporin contraindicated or not tolerated, consider infliximab).
- Step 3: A trial of Etrasimod (also known as Velsipity). This is a selective sphingosine 1-phosphate (S1P) receptor modulator.
- Indications for emergency surgery:
  - Surgery should be considered in patients with:
    - Acute fulminant ulcerative colitis
    - Toxic megacolon who have little improvement after 48-72 hours of intravenous steroids
    - Symptoms worsening despite intravenous steroids

_Note that an alternative is to initiate rescue therapy (with ciclosporin or infliximab) if the patient has a sub-optimal response to intravenous steroids but is stable enough to delay surgery. Surgery should be considered if patients fail to respond to rescue therapy within 3 days._

## Surgical options

- Panproctocolectomy with permanent end ilesotomy
- Colectomy with temporary end ileostomy (approximately 3 months later the ileostomy can be reversed by forming an ileorectal anastomosis, an alternative option is completion proctectomy with a permanent end ileostomy or ileal pouch anal anastomosis (IPAA)).

## Indications for elective surgery

- This can be considered in patients in which there is failure to induce remission by medical means.
- Surgical options include: panproctocolectomy with permanent end ileostomy or IPAA. An alternative is a total colectomy with ileorectal anastomosis (i.e. no stoma).

# Complications

## Short-term/acute complications

- Toxic megacolon: this describes a severe form of colitis, and is seen in around 15% of ulcerative colitis patients.
- Massive lower gastrointestinal haemorrhage: this occurs in up to 3% of patients.

## Long-term complications

- Colorectal cancer: this occurs in 3-5% of patients. There is a higher risk with disease duration, severity and extent of colitis, and concomitant primary sclerosing cholangitis (PSC).

_NICE guidance suggests offering colonoscopy surveillance to high risk patients._

- Cholangiocarcinoma: ulcerative colitis approximately doubles the risk of cholangiocarcinoma.
- Colonic strictures: these can cause large bowel obstruction.

## Variable-term complications

- Primary Sclerosing Cholangitis: this is characterised by inflammation and fibrosis of the extra- and intra-hepatic biliary tree and affects 3-7% of patients with ulcerative colitis. LFTs should be monitored yearly to check for the presence of PSC.
- Inflammatory pseudopolyps: these are areas of normal mucosa between areas of ulceration and regeneration.
- Increased risk of VTE - as with any inflammatory disease, but in the acute and chronic context, patients have an increased risk of developing blood clots, especially during flares

# References

[Click here for more information on NICE CKS about ulcerative colitis](https://cks.nice.org.uk/topics/ulcerative-colitis/)
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An abdominal x-ray showing toxic megacolon.
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A severe ulcerative colitis flare is indicated by a temperature above 37.8 degrees, requiring intravenous corticosteroids as part of the management.
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Surgery
A 23 year old man with known ulcerative colitis is referred to the Emergency Department by his GP for management of an acute flare. A CT scan shows evidence of colitis. He has a temperature of 38.6 degrees.

What is the most appropriate management?
a