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Common Ulcerative Colitis exam questions for medical finals, OSCEs and MRCP PACES

 

Question 1.

What are the micro- and macro-pathological hallmarks of ulcerative colitis?

  • Macro:
    • Inflammation extends proximally from the rectum (c.f. crohn’s, where the inflammation can be anywhere)
    • Hence inflammation can be classified as proctitis (limited to rectum), left-sided colitis (extending to sigmoid and descending colon), or pan-colitis (when entire colon involved)
    • Mucosa is reddened, inflamed, and bleeds easily.
    • Extensive ulceration, with islands of normal mucosa
  • Micro:
    • Superficial inflammation of mucosa (cf. Crohn’s, which is full-thickness)
    • Chronic inflammatory cell infiltrate in lamina propria (part of mucosa just under epithelium)
    • Crypt abcesses
    • Goblet (mucus-making) cell depletion

 

Question 2.

How do you classify severely acute presentations of colitis?

  • Calculate severity according to Truelove and Witts’ criteria:
    • More than 6 bloody stools per day (often nocturnal) and at least one of:
      • Temp >37.8 on 2/4 days
      • Hb<10.5
      • ESR>30
      • Pulse >90
      • Colon dilated>5.5

 

Question 3.

What are the extra-intestinal manifestations of UC?

  • Mouth ulcers (strictly part of the GI tract but often considered separately)
  • Erythema nodosum
  • Uveitis/episcleritis
  • Arthropathy
  • Pyoderma granulosum
  • Primary sclerosing cholangitis (75% of this is seen in ulcerative colitis patients)

 

Question 4.

What are the common complications of ulcerative colitis?

  • Acute
    • Toxic megacolon
      • Mortality approx. 20%
  • Primary sclerosing cholangitis
  • Colorectal carcinoma
    • Risk increased 10-20 times once patients have had UC for 20 years
      • 5-asa treatment probably reduces risk
    • Do colonoscopy starting at 10 years
      • Mucosal dysplasia on rectal biopsy is associated with cancer elsewhere in the bowel.
      • Then repeat at 1,3,or 5-year intervals depending on risk
  • Pouchitis after colectomy (with relapsing-remitting course)
  • Osteoporosis from steroid therapy
    • Bisphosphonates to over 65s on steroids and DEXA
    • Then bisphosphonates if T<1.5

 

Question 5.

What is the reason for checking TPMT levels in ulcerative colitis?

  • Thiopurine methyltransferase (TPMT) is involved in the metabolism of thiopurines (metcaptopurine and azathioprine)
  • TPMT levels should always be checked before starting thiopurines to avoid fatal administration to a patient with no or low TPMT levels.