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= Can’t distinguish between UC and Crohn’s using any parameters Indeterminate colitis = Overlapping features of UC and Crohn’s on histopath Other Classification Types
Steroid-refractory colitis Active disease despite prednisolone up to 0.75 mg/kg/day over a period of 4 weeks Steroid-dependent colitis i) Unable to reduce steroids below the equiva - lent of prednisolone 10 mg/day within 3 months of starting steroids, without recurrent active disease, or ii) Relapse <3 months after stopping steroids Immunomodulator-refractory colitis Relapse despite 3 months azathioprine Refractory distal colitis Relapse despite oral and topical steroids for 6–8 weeks Risk factors for ulcerative colitis Current Smoking (incl those who restart) protects vs developing UC, PSC and pouchitis and with a milder course of disease. Ex-smokers have a 70% greater risk of developing the disease, which is often more extensive and refractory than in those who have never smoked. Appendicectomy gives a 69% risk reduction vs onset and subsequent severity of UC. Appendicectomy protection + smoking is additionally protective, but not for PSC. Appendicectomy after UC onset - effect is less clear. NSAIDs exacerbate UC. COX-2 in the short term are safe. FDR’s of patients with UC have a 10–15- fold risk of developing the disease. Life time risk of UC for FDR is 95% chance of not developing the disease. Epidemiology Ulcerative Colitis
Disease Behaviour
Current genes of interest: -HLA-most associated with UC, -Interleukin-23 Receptor (IL23R) gene on chromosome 1 -DLG5 gene on chromosome 10 - Multidrug Resistance gene (MDR)-1 - Toll like Receptor (TLR) genes, Disease severity Disease Extent Types: -Ulcerative proctitis (limited to the rectum). -Left-sided colitis (up to the splenic flexure) and -Extensive colitis. Remission = Complete resolution of symp - toms and endoscopic mucosal healing Clinical Remission = BO< 3/day with no bleeding and no urgency Relapse = Rectal bleedng and diarrhoea and worse endoscopically Early relapse Relapse at <3 months Pattern of relapse Infrequent (>1/year), Frequent (>2 relapses/ year) Continuous (no remission) Active disease Defined according toTruelove and Witts criteria Fulminant colitis= 1 attack causing death in >1 year. Response = Decrease in the activity index of >30%, plus a decrease in the rectal bleeding and endoscopy subscores. Clinical features and risk factors: Bloody diarrhoea, rectal bleeding, and/or rectal urgency. Nocturnal defaecation. >6 weeks of loose stool differentiates UC from most infectious diarrhoea. Age of onset Peak: 15-30 Second Peak 50-80 Sex M = F Race Whites > Blacks Ethnic Jewish > Non-Jewish Incidence, per 100,000 (North America) 2-14 Prevalence around 150:100,000 20% pancolitis; 50% rectal only;1% rectal sparing 15% backwash ileitis pANCA positive more likely in procto-colitis patients Distribution of disease Use the Montreal classification (= maximal macr - scopic disease at colonoscopy). Cumulative probability of a relapsing course after 25y of follow up amounts to 90%. Disease activity in the first 2 years predicts the next 5y. Disease Genotyping
1.Truelove and Witt’s criteria. 2.CRP >45 mg/L at day 3 if admitted with severe colitis and >8 stools/day is v predictive for need for colectomy. 3.Of other positive (erythrocyte sedimentation rate, serum procalcitonin) or -ve (albumin) acute phase proteins none has demonstrated clear superiority. 4. Faecal calprotectin and lactoferrin, elastase and S100A12 may predict colonic inflammation. Not specific for UC. Colitis yet to be classified
Colitis: crampy abdominal pain, or ache over LIF before+relieved by defaecation Proctitis: rectal bleeding, urgency, tenesmus, and occasionally severe constipa - tion Insidiuos onset 15% present with severe attack Some get systemic symptoms including LOW, fever and tachycardia, or N+V EIMs can present before diarrrhoea and are presenting feature in 10%
Written by Dr Sebastian Zeki
