Ulcerative colitis.pptx

Lecture notes for medical students

1. Tips on using my ppt. You can freely download, edit, modify and put your name etc. Don’t be concerned about number of slides. Half the slides are blanks except for the title. First show the blank slides (eg. Aetiology ) > Ask students what they already know about ethology of today's topic. > Then show next slide which enumerates aetiologies. At the end rerun the show – show blank> ask questions > show next slide. This will be an ACTIVE LEARNING SESSION x three revisions. Good for self study also. See notes for bibliography.

2. Inflammatory bowel disease (IBD)

3. Inflammatory bowel disease (IBD) Inflammatory bowel disease (IBD) is an idiopathic disease caused by a dysregulated immune response to host intestinal microflora . The two major types of inflammatory bowel disease are ulcerative colitis (UC), which is limited to the colonic mucosa, and Crohn disease (CD), which can affect any segment of the gastrointestinal tract from the mouth to the anus, involves "skip lesions," and is transmural .  There is a genetic predisposition for IBD, and patients with this condition are more prone to the development of malignancy. 

4. Inflammatory bowel disease (IBD) Crohn disease Ulcerative colitis Inflammatory bowel disease (IBD) of undetermined type.

5. Introduction & History.

6. Introduction & History. Ulcerative colitis (UC) is idiopatic inflammatory disease potentially affecting the entire large bowel (colon and rectum). The inflammation is confined to mucosa. UC can go into remission and recur. Extraintestinal manifestations.

7. Aetiology

8. Aetiology Idiopathic Congenital/ Genetic Nutritional Deficiency/excess Traumatic Infections /Infestation Autoimmune Neoplastic (Benign/Malignant) Degenerative Iatrogenic Psychosomatic

9. Aetiology Certain types of food composition Oral contraceptives Protective effect of tobacco seen in ulcerative colitis Disturbed intestinal flora.

10. Pathology

11. Pathology Ulcerative colitis characteristically involves the large bowel. Starts in rectum and proceeds proximally upto terminal ileum ( backwater ileitis). No skip lesions. Ulcerative colitis is a lifelong illness. Mucosal disease. 

12. Pathology Rectum 95% Terminal ileum 10% Extraintestinal manifestations.

13. Gross

14. Microscopic Pathology

15. Microscopic Pathology Acute and chronic inflammatory infiltrate of the lamina propria , crypt branching, and villous atrophy are present in ulcerative colitis. Inflammation of the crypts of lieberkühn and abscesses. Granulomas are also seen in tuberculosis, yersiniosis , and can even be seen in ulcerative colitis

16. Microscopic Pathology The ulcerated areas are soon covered by granulation tissue Inflammatory polyps or pseudopolyps . Excessive fibrosis is not a feature of the disease

17. Grading

18. Grading Mild : Bleeding per rectum, fewer than four bowel motions per day Moderate : Bleeding per rectum, more than four bowel motions per day Severe : Bleeding per rectum, more than four bowel motions per day, and a systemic illness with hypoalbuminemia (< 30 g/L)

19. Clinical Features

20. Clinical Features Demography Symptoms Signs Prognosis Complications

21. Demography

22. Demography The annual incidence is 10.4-12 cases per 100,000 people, and the prevalence rate is 35-100 cases per 100,000 people. Three times more common than  Crohn disease White individuals living in Western industrialized nations  2-4 times higher in Ashkenazi Jews.

23. Demography Bimodal pattern, with a peak at 15-25 years and a smaller one at 55-65 years, although the disease can occur in people of any age. Slightly more common in women than in men. 

24. Demography:Geographical distribution Ulcerative colitis is more common in the Western and Northern hemispheres; the incidence is low in Asia and the Far East .   As new regions assume Western cultural practices, an increased prevalence of ulcerative colitis is usually found approximately 1 decade before the observed increase in Crohn disease.

25. Symptoms

26. Symptoms Rectal bleeding Frequent stools Mucous discharge from the rectum Tenesmus (occasionally) Lower abdominal pain and severe dehydration from purulent rectal discharge (in severe cases, especially in the elderly).

27. Symptoms In some cases, UC has a fulminant course marked by the following: Severe diarrhea and cramps Fever Leukocytosis Abdominal distention

28. Symptoms Colonic Crohn disease may be clinically indistinguishable from ulcerative colitis, with symptoms of bloody mucopurulent diarrhea , cramping abdominal pain, and urgency to defecate.

29. Symptoms: ExtraGI manifestations Uveitis Pyoderma gangrenosum Pleuritis Erythema nodosum Ankylosing spondylitis Spondyloarthropathies Primary sclerosing cholangitis (PSC) Recurrent subcutaneous abscesses unrelated to pyoderma gangrenosum   Multiple sclerosis   Immunobullous disease of the skin

30. Signs

31. Signs Normal in mild disease Mild tenderness in the lower left abdominal quadrant  Severe cases- Fever Tachycardia Significant abdominal tenderness Weight loss

32. Prognosis: IBD

33. Prognosis: IBD Both are lifelong diseases. For both conditions, the overall mortality has decreased steadily, and currently is less than 5%.  Both follow a more severe course in children and adolescents Both are at increased risk for the later development of cancer . The excess risk is limited to colorectal cancer

34. Prognosis Most patients with these diseases are able to maintain normal occupations and enjoy reasonably stable social and economic situations.  Ulcerative colitis is curable with proctocolectomy and ileostomy.

35. Complications

36. Complications Colonic perforation. Carcinoma. Benign strictures.

37. Investigations

38. Investigations Laboratory Studies Routine Special Imaging Studies Tissue diagnosis Cytology FNAC Histology

39. Diagnostic Studies

40. Diagnostic Studies Imaging Studies X-Ray USG CT Angiography MRI Endoscopy Nuclear scan

41. Investigations

42. Investigations Serologic markers (eg, antineutrophil cytoplasmic antibodies [ANCA], anti–  Saccharomyces cerevisiae  antibodies [ASCA]) Complete blood cell (CBC) count Comprehensive metabolic panel Inflammation markers (eg, erythrocyte sedimentation rate [ESR], C-reactive protein [CRP]) Stool assays

43. Imaging Studies Endoscopy and biopsy- Abnormal erythematous mucosa, with or without ulceration, extending from the rectum to a part or all of the colon Uniform inflammation, without intervening areas of normal mucosa (skip lesions tend to characterize Crohn disease) Contact bleeding may also be observed, with mucus identified in the lumen of the bowel

44. Colonscopy M ucosa hyperemic loss of the normal vascular pattern Normal colon Ulcerative Colitis

45. Imaging Studies Plain abdominal radiography Double-contrast barium enema examination Cross-sectional imaging studies (eg, ultrasonography, magnetic resonance imaging, computed tomography scanning) Radionuclide studies Angiography

46. UC: Barium enema strictures in the transverse and descending colon  Mucosal ulcers

47. Radiography

48. Radiography Pseudopolyposis   Deep ulcers The colon may appear shortened Loss of colonic haustra Toxic megacolon -massive colonic dilatation associated with an abnormal mucosal contour. Colonic perforation Thumbprinting  Long stricture/spasm of the ascending colon/cecum Increased postrectal space

49. Barium enema findings

50. Barium enema findings Colon may appear narrow , short and loose. Granular mucosa. Pseudopolyposis Mucosal ulcers Collar-button ulcers Double-tracking ulcers Burnt-out ulcerative colitis Similar radiographic signs may be seen in cases of infective diarrhea, crohn disease, ischemic colitis, drug-induced colitis, and amebic colitis

51. Computed Tomography

52. Computed Tomography Difuse , circumferential, symmetrical wall thickening with fold enlargement. Submucosal fat deposition Target sign The halo sign typically occurs in ulcerative colitis.

53. Differential Diagnosis

54. Differential Diagnosis Crohn's Disease Cathartic colon. Collagenous colitis Lymphocytic colitis Infectious colitis Ischemic colitis

55. Summary

56. Summary Ulcerative Colitis Crohn Disease Only colon involved Panintestinal Continuous inflammation extending proximally from rectum Skip-lesions with intervening normal mucosa Inflammation in mucosa and submucosa only Transmural inflammation   Perianal lesions No granulomas Noncaseating granulomas Perinuclear ANCA (pANCA) positive ASCA positive Bleeding (common) Bleeding (uncommon) Fistulae (rare) Fistulae (common)

57. Non Operative Therapy

58. Non Operative Therapy Mild disease confined to the rectum: Topical mesalazine via suppository (preferred) or budesonide rectal foam Left-side colonic disease: Mesalazine suppository and oral aminosalicylate (oral mesalazine is preferred to oral sulfasalazine) Systemic steroids, when disease does not quickly respond to aminosalicylates Oral budesonide After remission, long-term maintenance therapy (eg, once-daily mesalazine )

59. Non Operative Therapy Medical treatment of acute, severe UC Hospitalization Intravenous high-dose corticosteroids Alternative induction medications: Cyclosporine, Tofacitinib tacrolimus , infliximab, adalimumab , golimumab

60. Operative Therapy

61. Operative Therapy Indications for urgent surgery include the following: Toxic megacolon refractory to medical management Fulminant attack refractory to medical management Uncontrolled colonic bleeding

62. Operative Therapy Indications for elective surgery - Long-term steroid dependence Dysplasia or adenocarcinoma found on screening biopsy Disease being present for 7-10 years

63. Operative Therapy Surgical options - Total colectomy ( panproctocolectomy ) and ileostomy Total colectomy Ileoanal pouch reconstruction or ileorectal anastomosis In an emergency, subtotal colectomy with end-ileostomy

64. Operative Therapy UC is generally limited to the colon, apart from minimal distal "back-wash" ileitis; ulcerative colitis usually involves only the mucosal layer of the bowel, and, in some cases, superficial submucosa , unless there is fulminant colitis  may also manifest cecal or appendiceal patches of involvement that can simulate the "skip" lesions of CD

65. Prevention

66. Prevention

67. Take Home Messages

68. Take Home Messages UC is generally limited to the colon, apart from minimal distal "back-wash" ileitis; ulcerative colitis usually involves only the mucosal layer of the bowel, and, in some cases, superficial submucosa , unless there is fulminant colitis  may also manifest cecal or appendiceal patches of involvement that can simulate the "skip" lesions of CD

69. Take Home Messages risk of neoplastic transformation, the risk is higher continuous process, worse distally, with increased span of involvement distal to proximal, as the disease progresses Surgical intervention is better tolerated in UC

70. Get this ppt in mobile Download Microsoft PowerPoint from play store. Open Google assistant Open Google lens. Scan qr code from next slide.

71. Get this ppt in mobile Download Microsoft PowerPoint from play store. Open Google assistant Open Google lens. Scan qr code from next slide.

72. Get this ppt in mobile

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