Crypt abscesses = hallmark of UC

p-ANCA

Smoking is protective

Truelove-Witts criteria

BM per day

Blood in stool

Pyrexia

HR >90

Anemia

ESR

Perforation MC transverse colon.

All need colonoscopy 8 years after diagnosis for ALL IBD (crohn’s and UC) with 4 quadrant biopsies every 10 cm with at least 32 random biopsies

• Low risk pts get 1-5 yr exams depending on different society guidelines

• High risk - q1 yr cscope

• Will see a distorted vascular pattern

  • Loss of normally visualized endoscopic vascular pattern is another endoscopic feature of UC

  

• Biopsy

  • Random biopsies - 4-quadrant taken at 10 cm intervals with total of ≥32 biopsies
  • Directed biopsies by high-definition chromoendoscopy
    • Now we have chromoendoscopy

      • Mucosal dyes that enhance mucosal irregularities better at detecting dysplasia

        • Narrow-band imaging (optical filtering)

          

      • Invisible high-grade dysplasia → HD colonoscopy with chromoendoscopy with targeted and repeat random biopsies within 3-6 mo

      • This means chromoendoscopy should be used to follow up random colonoscopy biopsies that show high grade dysplasia

  • Confirmed invisible HG dysplasia OR multifocal low grade dysplasia → Tx: Total proctocolectomy +/- IPAA
    • includes findings of CRC or non-adenoma like dysplasia associated lesion or mass

• High grade dysplasia on polyp - repeat c-scope in 3 mo

• High risk for CRC if patient has: pancolitis, PSC (primary sclerosing cholangitis)

• The above biopsy technique still missed a lot of cancer

Avoid NSAIDS, can cause flares

HLA B27 - sacroiliitis, ankylosing spondylitis, ulcerative colitis

Pyoderma gangrenosum treatment - steroids

• Resolves in only about 50% of patients s/p colectomy

If patient has UC and is diagnosed with primary sclerosing cholangitis, needs immediate colonoscopy and random bx. PSC increases risk of CRC significantly

• PSC also increases risk of cholangiocarcinoma

At 20 years the case is strong for prophylactic colectomy in patients with: primary sclerosing cholangitis, family history of colon CA, young age at dx, left sided colitis

MC extra intestinal manifesting requiring total colectomy → failure to thrive in children

Does not get better with total colectomy → ankylosing spondylitis, sacroiliitis, and primary sclerosing cholangitis

Gets better → ocular symptoms, arthritis, anemia, pyoderma gangrenosum

Initial Tx:

• Methylprednisolone 60 mg (16-20 mg q8 hrs) (Glucocorticoids)
• Oral prednisone is used as transition therapy after IV steroid therapy
• If fails → infliximab (anti-TNF) or cyclosporine
• Aminosalicylates are maintenance

Acute surgery for UC → Fulminant colitis

• TAC + end ileostomy + mucous fistula of rectal stump
• Routinely preserve superior rectal artery (good blood supply to the rectal stump, aid in healing rectal staple line)
• Terminal branches of the IMA are spared until proctectomy
• Ileocolic artery is routinely spared to allow for collateral blood flow to the future J-pouch
• Divide the rectum above the posterior peritoneal reflection in the abd and above the level of sacral promontory

Elective surgery for UC

• Refractory to medical management, severe GI bleeding, dysplasia on screening colonoscopy → Total abdominal colectomy with ileal J pouch
  • Ileal J pouch should be about 15-20 cm
• Ileal pouch anal anastomosis, J pouch: if you have tension creating the J pouch, do these maneuvers:
  • Mobilize small bowel to the 3rd portion of duo
  • Superficial dissection of anterior and posterior mesentery over tension lines along SMA vessels
• Many ileoanal J pouch (15%) need to eventually be taken down due to: incontinence (MC REASON), dysplasia/CA, refractory infectious pouchitis - TAKE DOWN WITH APR
  • MC long term complication of IPAA is pouchitis (23-59%)
    • Sx: increased stool frequency, bleeding per rectum
    • Tx – po Ciprofloxacin treatment is better than flagyl!!! Newest studies
• Coloplasty - longitudinal colotomy, closed transversely
• If surgery is being done for dysplasia → Gold standard is: Restorative proctocolectomy with ileal pouch anal anastomaosis (RPC-IPAA)
  • Provides best chance to live normal life
  • End ileostomy for patients with poor anal sphincter function

Severe colitis fulminant colitis (try medical tx 1st) progresses to toxic colitis/toxic megacolon (Colon >6 cm) = fever, tachycardia, leukocytosis

• If steroids fail, then give infliximab (90%) can avoid surgery
• No colonoscopy with toxic megacolon or toxic colitis

If patient has anal incontinence → do not give J pouch ever, do total proctocolectomy with ileostomy

If surgery is emergent (perforation, high dose steroids, toxic colitis, unstable) → subtotal colectomy with ileostomy