Study Notes Sample

Ulcerative Colitis (UC)

A 35-year-old female with a history of ulcerative colitis presents to the outpatient clinic with worsening abdominal pain, diarrhea, and rectal bleeding. You are the surgical registrar in the clinic.

Overview

  • Definition: Ulcerative colitis (UC) is a chronic inflammatory bowel disease (IBD) characterized by inflammation of the colonic mucosa, primarily affecting the rectum and extending proximally in a continuous manner.

Epidemiology

  • Incidence: Common in Western countries.
  • Age of Onset: Bimodal distribution (15-30 years and 50-70 years).
  • Gender: Slightly more common in males.

Pathophysiology

  • Inflammation: Limited to the mucosa and submucosa.
  • Distribution: Begins in the rectum (proctitis) and can extend proximally to involve the entire colon (pancolitis).
  • Immune Dysregulation: Abnormal immune response to colonic microbiota.

Clinical Features

  • Symptoms:
    • Diarrhea (often bloody).
    • Abdominal pain (typically lower left quadrant).
    • Tenesmus (feeling of incomplete defecation).
    • Urgency.
    • Systemic symptoms: Fever, weight loss, fatigue.
  • Extraintestinal Manifestations:
    • Joints: Arthritis.
    • Skin: Erythema nodosum, pyoderma gangrenosum.
    • Eyes: Uveitis, episcleritis.
    • Hepatobiliary: Primary sclerosing cholangitis (PSC).

Diagnosis

  • Clinical Evaluation:
    • History and physical examination.
    • Stool studies to exclude infection.
  • Endoscopy:
    • Sigmoidoscopy/Colonoscopy: Visualization of continuous mucosal inflammation, erythema, friability, ulceration.
    • Biopsy: Histopathological confirmation showing crypt abscesses, mucosal and submucosal inflammation.
  • Imaging:
    • Abdominal X-ray: May show colonic dilation in severe cases.
    • CT/MRI: Assess complications (e.g., toxic megacolon).
  • Laboratory Tests:
    • Elevated inflammatory markers (CRP, ESR).
    • Anemia, hypoalbuminemia.
    • Perinuclear antineutrophil cytoplasmic antibodies (pANCA) positive in some patients.

Management

  1. Medical Treatment:
    • Aminosalicylates (5-ASA): Mesalamine, sulfasalazine (mild to moderate disease).
    • Corticosteroids: Prednisone, budesonide (moderate to severe disease, induction of remission).
    • Immunomodulators: Azathioprine, 6-mercaptopurine (maintenance therapy).
    • Biologics: Anti-TNF agents (infliximab, adalimumab), integrin inhibitors (vedolizumab), JAK inhibitors (tofacitinib).
    • Antibiotics: For secondary infections or complications.
  2. Surgical Treatment:
    • Indications: Refractory disease, dysplasia/cancer, complications (e.g., perforation, toxic megacolon).
    • Procedures:
      • Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) (most common).
      • Subtotal colectomy with end ileostomy (in emergency situations).
  3. Lifestyle and Supportive Care:
    • Diet: Nutritional support, avoiding trigger foods.
    • Smoking cessation.
    • Psychological support.

Complications

  • Acute:
    • Severe bleeding.
    • Toxic megacolon.
    • Perforation.
  • Chronic:
    • Colorectal cancer (increased risk with long-standing disease).
    • Strictures.
    • Primary sclerosing cholangitis (PSC).

Surveillance

  • Colonoscopy: Regular screening for dysplasia and colorectal cancer, starting 8-10 years after diagnosis, then every 1-2 years.

Key Points

  • Pathology: Inflammation limited to the mucosa and submucosa, starts in the rectum.
  • Symptoms: Bloody diarrhea, abdominal pain, urgency, tenesmus.
  • Diagnosis: Clinical evaluation, endoscopy with biopsy, stool studies.
  • Treatment: 5-ASA, corticosteroids, immunomodulators, biologics, surgery for refractory cases.
  • Complications: Toxic megacolon, colorectal cancer, primary sclerosing cholangitis.
  • Surveillance: Regular colonoscopy for dysplasia and cancer screening.
Course: Free Samples
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