Treatment Options for Ulcerative Colitis

Ulcerative colitis (UC) is a chronic inflammatory bowel disease that affects the rectum and may spread to the colon. The main symptom is bloody diarrhea, and the disease follows a relapsing and remitting course. The goal of UC management is to treat acute relapses, prevent relapses, and detect cancers early.

Mesalazine is an effective first-line treatment for mild to moderate UC, which involves enemas and oral medication. For moderately active cases, oral aminosalicylates, topical aminosalicylates, and corticosteroids are used. Azathioprine is an immunomodulator that is rarely used to induce remission but is used to keep patients in remission. Hydrocortisone is a systemic steroid used for severe cases. Infliximab is an anti-tumor necrosis factor biologic used for moderate to severe cases that are refractory to standard treatment. Methotrexate is an alternative immunomodulator for patients who cannot tolerate azathioprine. It is important to discuss adequate contraception with patients on methotrexate due to its teratogenicity.

Understanding Treatment Options for Ulcerative Colitis

Medication Management for Constipation: Understanding the Role of Different Laxatives

When managing constipation in patients, it is important to consider the underlying cause and choose the appropriate laxative. For example, in patients taking opiates like codeine phosphate, a stimulant laxative such as Senna should be co-prescribed to counteract the constipating effects of the medication. On the other hand, bulk-forming laxatives like Ispaghula husk may be more suitable for patients with low-fibre diets. It is also important to avoid medications that can worsen constipation, such as loperamide, and to be cautious with enemas, which can cause complications in certain patients. By understanding the role of different laxatives, healthcare providers can effectively manage constipation and improve patient outcomes.

The only definitive treatment for advanced hepatic disease in primary sclerosing cholangitis (PSC) is orthotopic liver transplantation (OLT). Patients with intractable pruritus and recurrent bacterial cholangitis are specifically indicated for transplant. Although there is a 25-30% recurrence rate in 5 years, outcomes following transplant are good, with an 80-90% 5-year survival rate. PSC has become the second most common reason for liver transplantation in the United Kingdom. Other treatments such as steroids, azathioprine, methotrexate, and pentoxifylline have not been found to be useful. Antibiotic prophylaxis with ciprofloxacin or co-trimoxazole can be used to treat bacterial ascending cholangitis, but it will not alter the natural course of the disease.

When differentiating between ulcerative colitis and Crohn’s disease, it is important to note that crypt abscesses are typical for ulcerative colitis, while other options are more commonly found in Crohn’s disease. Ulcerative colitis is the most common form of inflammatory bowel disease, with inflammation starting in the rectum and spreading upwards in a contiguous fashion. Patients typically experience left-sided abdominal pain, cramping, bloody diarrhea with mucous, and unintentional weight loss. Extra-intestinal manifestations may include seronegative arthropathy and pyoderma gangrenosum. Barium enema and colonoscopy are used to diagnose ulcerative colitis, with the latter revealing diffuse and contiguous ulceration and inflammatory infiltrates affecting the mucosa and submucosa only. Complications of long-term ulcerative colitis include large bowel adenocarcinoma, toxic megacolon, and primary sclerosing cholangitis. In contrast, Crohn’s disease usually presents with right-sided abdominal pain, watery diarrhea, and weight loss. Barium enema and colonoscopy reveal multiple ulcers and bowel wall thickening, with the microscopic appearance showing a mixed acute and chronic transmural inflammatory infiltrate with non-caseating granulomas. Terminal ileum involvement is typical for Crohn’s disease, while stricturing and fistula formation are common complications due to its transmural inflammatory nature. Overall, while both ulcerative colitis and Crohn’s disease are systemic illnesses, they have distinct differences in their clinical presentation and diagnostic features.

Coeliac disease is a condition where the lining of the small intestine is abnormal and improves when gluten is removed from the diet. It is caused by an immune response to a component of gluten called α-gliadin peptide. Symptoms can occur at any age but are most common in infancy and in adults in their 40s. Symptoms include abdominal pain, bloating, diarrhea, delayed puberty, and anemia. Blood tests are used to diagnose the disease, and a biopsy of the small intestine can confirm the diagnosis. Treatment involves avoiding gluten in the diet. Crohn’s disease and ulcerative colitis have different symptoms, while irritable bowel syndrome and carcinoid syndrome are unlikely in this case.

Effects of Gastrectomy on Nutrient Absorption and Digestion

Gastrectomy, whether partial or complete, can have significant effects on nutrient absorption and digestion. One of the most important consequences is the loss of intrinsic factors, which are necessary for the absorption of vitamin B12 in the ileum. Intrinsic factor is produced by the gastric parietal cells, which are mostly found in the body of the stomach. Without intrinsic factor, vitamin B12 cannot be absorbed and stored in the liver, leading to megaloblastic anemia and potentially serious complications such as dilated cardiomyopathy or subacute degeneration of the spinal cord.

Another consequence of gastrectomy is the loss of storage ability, which can cause early satiety and abdominal bloating after meals. This is due to the fact that the stomach is no longer able to hold as much food as before, and the remaining small intestine has to compensate for the missing stomach volume.

Achlorohydria is another common problem after gastrectomy, as the parietal cells that produce hydrochloric acid are also lost. This can lead to a range of symptoms such as abdominal bloating, diarrhea, indigestion, weight loss, malabsorption, and bacterial overgrowth of the small intestine.

Failed gastric emptying is not a major concern after gastrectomy, as it is unlikely to cause vitamin B12 deficiency. However, increased upper GI gut transit can affect the rate of nutrient absorption and lead to symptoms such as diarrhea and weight loss. Overall, gastrectomy can have significant effects on nutrient absorption and digestion, and patients should be closely monitored for any signs of malnutrition or complications.

Differential Diagnosis for RUQ Pain: Acute Cholecystitis, Pancreatitis, Ascending Cholangitis, Gallstone Ileus, Biliary Colic

When a patient presents with right upper quadrant (RUQ) pain, it is important to consider several potential diagnoses. A positive Murphy’s sign, which is pain on deep palpation of the RUQ during inspiration, strongly suggests gallbladder involvement and makes acute cholecystitis the most likely diagnosis. Biliary colic is less likely as the patient is febrile, and ascending cholangitis is unlikely as the patient is not jaundiced. Pancreatitis is a possibility, but the pain is typically focused on the epigastrium and radiates to the back.

Gallstone ileus is a rare condition in which a gallstone causes obstruction in the small bowel. It would present with symptoms of obstruction, such as nausea, vomiting, and abdominal pain, with complete constipation appearing later. However, since this patient’s bowels last opened this morning, acute cholecystitis is a much more likely diagnosis.

It is important to consider all potential diagnoses and rule out other conditions, but in this case, acute cholecystitis is the most likely diagnosis. Treatment involves pain relief, IV antibiotics, and elective cholecystectomy.

Treatment Options for Moderate Exacerbation of Distal Ulcerative Colitis

Distal ulcerative colitis can cause moderate exacerbation, which is characterized by 4-6 bowel movements per day, pulse rate <90 bpm, no anemia, and ESR 30 or below. The first-line therapy for this condition includes topical or oral aminosalicylate, with mesalazine or sulfasalazine being the most commonly used options. However, these medications can cause side-effects such as diarrhea, vomiting, abdominal pain, and hypersensitivity. In rare cases, they may also lead to peripheral neuropathy and blood disorders. Codeine phosphate is not used in the management of ulcerative colitis, while ciclosporin is reserved for acute severe flare-ups that do not respond to corticosteroids. Infliximab, a monoclonal antibody against tumour necrosis α, is used for patients who are intolerant to steroids or have not responded to corticosteroid therapy. However, it can cause hepatitis and interstitial lung disease, and may reactivate tuberculosis and hepatitis B. Steroids such as prednisolone can be used as second-line treatment if the patient cannot tolerate or declines aminosalicylates or if aminosalicylates are contraindicated. Topical corticosteroids are usually preferred, but oral prednisolone can also be considered.

Differentiating Autoimmune Liver Disease: Antibody Tests

When a patient presents with abnormal liver function tests and a young age, autoimmune liver disease is a possible diagnosis. To confirm this, the most specific antibody test is for anti-smooth muscle antibodies, which are positive in about 80% of patients with autoimmune liver disease.

On the other hand, anti-mitochondrial antibodies are the hallmark of primary biliary cholangitis, with over 95% of patients being subtype M2 positive. Hepatitis A IgM antibodies are elevated in patients with acute hepatitis A infection, but not in autoimmune liver disease.

While raised anti-nuclear antibodies (ANAs) are seen in many autoimmune conditions, they are not very specific for autoimmune hepatitis. Positive ANAs are also seen in other diseases like systemic sclerosis, rheumatoid arthritis, and Sjögren syndrome. Similarly, anti-Smith antibodies are seen in about 20% of patients with systemic lupus erythematosus but are not specific for autoimmune liver disease.

In conclusion, antibody tests play a crucial role in differentiating autoimmune liver disease from other liver conditions.

In cases of suspected variceal bleeding, the priority medication to administer is terlipressin. This drug causes constriction of the mesenteric arterial circulation, leading to a decrease in portal venous inflow and subsequent reduction in portal pressure, which can help to control bleeding. Band ligation should be performed after administering terlipressin, and if bleeding persists, a transjugular intrahepatic portosystemic shunt (TIPS) may be necessary. Antibiotics may also be given prophylactically, but they do not directly affect bleeding. Clopidogrel should be avoided as it can worsen bleeding, while omeprazole may be used according to hospital guidelines. Tranexamic acid is not indicated for oesophageal variceal bleeds.