Ulcerative colitis
Key points
25% present in childhood
Approx 20% need colectomy within 5 years
Genetic and environmental factors
HLA-DRB1/DQB - susceptibility
Colonic inflammation, ulceration and bleeding
Extra intestinal manifestations
Arthritis
Ankylosing spondylitis
Uveitis/Episcleritis
Erythema nodosum
Pyoderma gangrenosum
Primary sclerosing cholangitis
Nephrolithiasis
Paediatric ulcerative colitis activity index
- 6 categories
- Abdominal pain
- Rectal bleeding
- Stool consistency
- Episodes of stooling
- Nocturnal stooling
- Activity level
>64 = severe disease
Used for monitoring disease severity and response to treatment - check daily
Investigations
Stool cultures for infective colitis
Faecal calprotectin
Antinuclear cytoplasmic antibodies - more common in ulcerative colitis (UC)
Anti-Saccharomyces cerevisiae antibodies - more common in Crohns disease
Colonoscopy features: Erythema + ulceration + pseudopolyps - biopsy
Histology
See Crohns section
Radiology
‘Lead pipe’ colon in MRI with chronic disease
Thumb printing on AXR/MRI
Management
Induction therapy
Mild disease - 5 ASA,
Moderate/severe - Steroids
Second line - Tacrolimus, Infliximab
Maintenance
Mild disease - 5 ASA
Moderate/Severe - 6MP or infliximab
Urgent steroids for Uveitis
Optimise nutrition - aim for normal albumin
May need PN - no specific use of elemental feeds
Surgery
Objectives are to safely remove colon and rectum, then reconstruct if able
Subtotal colectomy with ileostomy should be performed in emergencies to avoid a difficult pelvic dissection to remove an inflammed rectum which would risk incontinence
Completion proctectomy and ileo-anal J-pouch anastomosis can be performed at a later date with or without covering ileostomy
Alternatively an elective pan-proctocolectomy and J pouch can be performed in stable patients
Indications for emergency surgery:
Exsanguination
Perforation
Progression of toxic mega colon despite maximum medical therapy
Indications for elective surgery:
Failure of medical management (steroid dependence, antibodies to biologics)
Patient preference
Malignancy/dysplasia (semi-elective)
Pouch complications - pelvic sepsis, incontinence, infertility, pouchitis, development of Crohns disease in pouch
Pouchitis - give PO metronidazole, washouts - PR exam, contrast, EUA + biopsy for Crohns
If found later to have Crohns - do not necessarily need to remove
Patients with indeterminate colitis can still have J pouch, but pouch survival 60% at 20 years compared to 90% in UC
Standard scenario
Patient with flare of UC
Ensure resuscitated + stable
History
Duration of symptoms
Bleeding
Weight loss
Previous surgery
Examination
Cachexia, anaemia
Abdomen for peritonitis
Investigations
Bloods - anaemia + inflammatory markers
Daily AXR + Paediatric UC activity index
Management
If failing medical management but stable - start PN and optimise
If toxic megacolon - needs IV methylprednisolone + Vancomycin/Metronidazole
If no response after 48 hours - Subtotal colectomy
Indications for emergency subtotal colectomy:
1. Uncontrollable haemorrhage
2. Perforation/peritonitis
3. Non-response to IV methylprednisolone after 48 hours
Post op colectomy - rectal stump flushes daily
References
Lillehei, Craig W, et al. "Ulcerative Colitis." Pediatric Surgery NaT, American Pediatric Surgical Association, 2022. Pediatric Surgery Library, www.pedsurglibrary.com/apsa/view/Pediatric-Surgery-NaT/829046/all/Ulcerative_Colitis.
Turner D, Otley AR, Mack D, Hyams J, de Bruijne J, Uusoue K, Walters TD, Zachos M, Mamula P, Beaton DE, Steinhart AH, Griffiths AM. Development, validation, and evaluation of a pediatric ulcerative colitis activity index: a prospective multicenter study. Gastroenterology. 2007 Aug;133(2):423-32. doi: 10.1053/j.gastro.2007.05.029. Epub 2007 May 21. PMID: 17681163.