Inflammatory bowel disease (ulcerative colitis): Clinical sciences

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Introduction0:00–0:36

Inflammatory bowel disease, or IBD, is a condition characterized by chronic gastrointestinal tract inflammation. It can be subdivided into Ulcerative Colitis and Crohn Disease.
Ulcerative Colitis, or UC, primarily affects the colon and is characterized by continuous ulcerations of the mucosa and submucosa, which may lead to abdominal pain, bloody diarrhea, and tenesmus.
Management is based on the severity of disease and they can be categorized as mild to moderate, moderate to severe, or acute severe.

Unstable patients0:36–2:13

Now, when assessing an individual with suspected ulcerative colitis, you should first perform an ABCDE assessment to determine if they are stable or unstable.
Unstable individuals might present with signs of shock, like tachycardia and hypotension, so you might have to secure their airway, breathing, and circulation before further workup.
Unstable patients may also have signs of complications like toxic megacolon, perforated colon, or severe refractory hemorrhage.
These patients should be hospitalized, and given intravenous fluids and antibiotics. Once they are stable, you should find out what caused the instability.
If the patient presents with pallor and profuse rectal bleeding, consider anemia and hypovolemic shock due to severe refractory hemorrhage.
In this situation, begin systemic corticosteroids and transfuse blood products. If the abdomen is distended or firm, consider toxic megacolon.
An X-ray might reveal an enlarged colon and possibly signs of perforation, like pneumoperitoneum. These patients should also have stool studies to rule out C.
difficile infection. A high yield fact to keep in mind about unstable patients is that you should avoid colonoscopy because there is a high risk of colon perforation.
If an unstable patient has evidence of severe refractory hemorrhage, toxic megacolon, or perforated viscus, you can consult surgery for possible colectomy.
Now, when it comes to stable individuals, the first step is to obtain a focused history and physical exam. History typically reveals diffuse or periumbilical crampy abdominal pain, bloody diarrhea, tenesmus, and fecal urgency.

History & Physical, Stool studies, and Labs2:13–3:51

Some patients report extra-intestinal symptoms, like eye pain, joint pain, and rashes. Physical exam usually reveals an abdomen that’s tender to palpation.
Additionally, there might be extra-intestinal manifestations, such as eye findings like uveitis and episcleritis; skin findings like tender red spots that indicate erythema nodosum and painful ulcerations associated with pyoderma gangrenosum; or even jaundice that might point to Primary Sclerosing Cholangitis.
Finally, the rectal exam might reveal bright red blood and discomfort on palpation. Now, to differentiate IBD from other diagnoses with similar presentations, such as Irritable Bowel Syndrome or IBS and C.difficile colitis, you should obtain stool laboratory studies.
Fecal calprotectin is a marker of colon inflammation. Since IBS does not cause colon inflammation, a positive fecal calprotectin would increase your suspicion for IBD.
Similarly, negative stool studies for pathogens help rule out infectious etiologies like C.difficile colitis. Next, you should check blood work, which may reveal anemia and elevated inflammatory markers such as CRP and ESR.
If the H&P, imaging, and lab findings suggest IBD, the next step is to confirm the diagnosis with a colonoscopy with biopsies.

Colonoscopy with biopsies3:51–5:34

On colonoscopy, you may observe erythema, a decreased or absent vascular pattern, friability, and ulcerations in a continuous pattern.
UC usually starts in the rectum, which is called proctitis, and typically progresses to the splenic flexure, which is referred to as left-sided colitis.
Sometimes it can extend beyond the splenic flexure, which is then called extensive colitis. Some individuals develop inflammation just beyond the ileocecal valve, called backwash ileitis, so don’t forget to visualize the ileum during colonoscopy.
Biopsy of the ileum with histopathologic evaluation will help differentiate UC from Crohn Disease, in which the ileum is the most commonly affected segment of the GI tract.
Typical histopathologic findings of UC on biopsy include mucosal and submucosal chronic inflammation, erosions, ulcerations, and crypt abscesses.After you confirm the diagnosis of UC with colonoscopy, you should determine the severity of the disease based on signs and symptoms like frequency of stools per day, amount of blood in the stool, the presence of cramps and tenesmus, amount of weight loss, and colonoscopy findings.
Using these findings, UC can be broken down into three categories: mild to moderate, moderate to severe, and acute severe ulcerative colitis.
Let’s start by looking at the management of someone with mild to moderate UC. They may report 0-3 stools per day with intermittent blood, mild crampy abdominal pain, and tenesmus.

Mild to moderate UC5:34–7:56

They usually don’t have weight loss; signs of systemic toxicity, such as fever; or anemia. Their inflammatory markers are typically normal.
When it comes to treatment, the goal is to induce remission using induction therapy, which differs based on colon involvement.
You can often treat isolated proctitis with just rectal suppositories of 5-aminosalicylates, or 5-ASA, like mesalamine. However, if there’s left-sided or extensive colitis, you should administer oral 5-ASA along with 5-ASA enemas.
If you manage to induce remission, continue the current treatment. This is referred to as maintenance therapy since it’s used to keep the person in remission.
After 6-12 months, follow up with the patient to evaluate clinical symptoms and perform a colonoscopy to look for signs of relapse.
If induction therapy fails, you should continue the 5-ASA and add local corticosteroids. For those with proctitis, you can add a hydrocortisone suppository, but if there’s proctosigmoiditis, or UC that extends to the sigmoid, you can use the corticosteroid budesonide as a foam or enema.
Individuals with left-sided colitis, which goes up to the splenic flexure, or extensive colitis, which goes past the splenic flexure, should use oral budesonide.
Even though budesonide is used orally, it is minimally absorbed in most of the GI tract, so it acts locally in the colon.
If this induces remission, continue the current medical therapy, taper off the corticosteroids, and follow up with a colonoscopy in 6-12 months.
However, if this doesn’t induce remission, continue 5-ASA therapy and switch the local corticosteroids to systemic ones, like prednisone.
Once again, if remission is induced, continue the current medical therapy, taper off the corticosteroids, and follow up with a colonoscopy in 6-12 months.
If this doesn’t induce remission, switch to treatment of moderate to severe UC.And now, moving on to individuals with moderate to severe UC.
They usually report 4 to 6 loose bloody stools per day, mild to moderate crampy abdominal pain, and tenesmus. They typically don’t present with weight loss or signs of systemic toxicity.

Moderate to severe UC7:56–9:26

They might have mild anemia and slightly elevated inflammatory markers. When it comes to treatment, you should start with monoclonal antibodies, like adalimumab, golimumab, or infliximab.
If this induces remission, continue the current medical therapy, and schedule a colonoscopy in 6 to 12 months. But, if this doesn’t induce remission, you should start the patient on systemic corticosteroids, like oral prednisone.
You can continue the monoclonal antibody they were using and add an immunomodulator like 6 mercaptopurine. Alternatively, you can switch to a different monoclonal antibody, like anti-integrins such as vedolizumab; or to a JAK inhibitor, like tofacitinib.
If this induces remission, continue the current medical therapy, taper off the corticosteroids, and schedule a follow-up colonoscopy in 6 to 12 months.
If this doesn’t achieve remission, you should switch the patient to the regimen for acute severe ulcerative colitis.Alright, let’s look at the most severe patients who fall into the final category of UC, called acute severe Ulcerative Colitis.
They might report having more than 6 loose bloody stools per day, severe crampy abdominal pain, tenesmus, weight loss, evidence of systemic toxicity, severe anemia that may require transfusion, and elevated inflammatory markers.

Acute Severe UC (ASUC)9:26–11:40

Due to these symptoms, they should be hospitalized. For this group, the induction therapy is also referred to as rescue therapy because it’s the last step before surgery.
First, you should start them on intravenous systemic corticosteroids, like methylprednisolone. If this induces remission, taper off the corticosteroids and start them on a monoclonal antibody like infliximab, and possibly a thiopurine immunomodulator such as 6 mercaptopurine or azathioprine.
Remember to schedule a colonoscopy in 6 to 12 months. Now, if this doesn’t achieve remission, continue the methylprednisolone and add either a monoclonal antibody like infliximab or the immunosuppressive drug cyclosporine.
If this induces remission, taper off the corticosteroids. If you used monoclonal antibodies for induction, you should add an immunomodulator such as 6 mercaptopurine to therapy for maintenance.
However, if you used cyclosporine for induction, switch to a thiopurine immunomodulator like azathioprine or a monoclonal antibody such as the anti-integrin vedolizumab.
As before, schedule a colonoscopy in 6 to 12 months. Finally, if you can’t induce remission, consult surgery for possible colectomy, which is considered curative for Ulcerative Colitis.Regardless of the severity of UC, it’s important to educate all individuals on the importance of avoiding potentially dangerous medications.
For example, they should be advised to avoid NSAIDs, which can increase the risk of bleeding and further exacerbate UC. Additionally, they should limit opioids and anticholinergics, which can increase the risk of complications, such as toxic megacolon.Alright, as a quick recap… management of ulcerative colitis, starts with a history and physical, fecal calprotectin, stool study, and imaging studies that will point to IBD.
To confirm Ulcerative Colitis, you’ll need a colonoscopy with biopsy. This will also help you determine severity which guides management.

Review11:40–12:39

For mild to moderate, induction therapy is typically a 5-ASA, but a local corticosteroid needs to be added if there’s no remission.
For moderate to severe, induction therapy is a monoclonal antibody. An oral systemic corticosteroid and immunomodulator or Jak inhibitor should be added if there’s no remission.
Finally, for acute severe UC, start them on IV systemic corticosteroids for induction therapy. You may need a surgical consult for colectomy if there’s no remission.
For all three severities, once UC is in remission, be sure to follow up with a colonoscopy in 6 to 12 months. therapy you may need a surgical consult for Colectomy If there is no remission is for all three severt once is in remission be sure to follow up with a colonoscopy in 6 to 12 months