Questions to Be Asked on Ulcerative Colitis PPT

1. Definition & Epidemiology

1. What is ulcerative colitis (UC)? How does it differ from Crohn's disease in terms of disease location?
2. What is the peak age of onset for UC? Is there a second peak?
3. What is the sex distribution in UC? (Answer: 1:1, F:M)
4. Name the three anatomic subtypes of UC based on extent. (Proctitis, left-sided/proctosigmoiditis, pancolitis)
5. At the time of diagnosis, what percentage of UC patients have pancolitis?

2. Pathology & Histopathology

1. UC starts from which part of the colon and extends in what pattern? (Rectum, continuous proximal extension)
2. Which layers of the bowel wall are involved in UC? (Mucosa and submucosa only - NOT transmural)
3. What are the classic early histopathological findings in UC?
   • Epithelial necrosis
   • Acute inflammatory infiltrate in lamina propria
   • Cryptitis and crypt abscesses
4. What histological features are seen in chronic UC? (Lymphocytic infiltrate + crypt architectural distortion)
5. What are pseudopolyps and how do they form in UC?
6. What endoscopic changes occur in the colon with long-standing UC? (Loss of haustral folds, shortening, narrowing)

3. Clinical Features

1. List the cardinal symptoms of UC. (Hematochezia, bloody diarrhea, tenesmus, mucus in stool, urgency, abdominal pain)
2. Why can patients with proctitis or proctosigmoiditis paradoxically develop constipation?
3. What systemic symptoms suggest severe/extensive disease in UC?
4. What is "backwash ileitis"? Is it true ileal involvement? (Spillover from cecum, NOT true UC of the ileum)

4. Extraintestinal Manifestations

1. What is the most common extraintestinal manifestation of IBD? (Arthropathy - 10-20%)
2. Name the skin manifestations of IBD. (Erythema nodosum ~10-15%, Pyoderma gangrenosum ~1-2%)
3. Which eye conditions are associated with IBD? (Uveitis, episcleritis - 5-15%)
4. Which hepatobiliary complication is STRONGLY associated with UC specifically? (Primary sclerosing cholangitis - PSC)
5. What percentage of PSC patients have underlying IBD? (70-80%)
6. What type of renal stones are more common in IBD? (Calcium oxalate in fat malabsorption; uric acid in volume depletion)

5. Diagnosis

1. What is the gold standard for diagnosing UC? (Colonoscopy with histopathology)
2. Describe the endoscopic appearance of mild UC. (Mucosal erythema, loss of vascular pattern, granular/edematous mucosa)
3. In severe UC, what endoscopic findings are noted? (Friable mucosa, contact bleeding, ulceration)
4. What serological marker is elevated in UC but not Crohn's disease? (pANCA - present in ~55% of UC patients)
5. What antibody is elevated in Crohn's disease but NOT UC? (ASCA - anti-Saccharomyces cerevisiae antibodies)
6. What laboratory findings are seen in active UC? (Anemia, elevated ESR/CRP, elevated fecal calprotectin, hypoalbuminemia, leukocytosis)
7. What is the role of fecal calprotectin in UC? (Elevated in active disease, lower in remission - used to monitor disease activity)
8. What features on histology are consistent with UC (vs. Crohn's)? (Crypt distortion, continuous mucosal inflammation from rectum, absence of granulomas, no small bowel disease)

6. Treatment

1. What factors determine the choice of therapy in UC? (Anatomic distribution, severity of disease, risk/prognosis)
2. What is the first-line drug for active mild-moderate UC? (Oral 5-ASA / aminosalicylates)
3. What is the route of drug delivery for proctitis vs. left-sided colitis? (Suppository for proctitis; enema/foam for left-sided disease up to splenic flexure)
4. Is topical 5-ASA or topical corticosteroid superior for active proctitis? (Topical 5-ASA is superior)
5. When are oral corticosteroids indicated in UC? (>5-6 bowel movements/day, rapid response needed, or failure of 5-ASA after 3-4 weeks)
6. What is the standard corticosteroid dose for severe UC? (Prednisone 40 mg/day orally; methylprednisolone 60 mg IV for severe disease)
7. What is budesonide MMX? What is its advantage? (Extended-release budesonide with fewer systemic steroid side effects)
8. What are the options when IV corticosteroids fail within 3-5 days in severe UC?
   • Colectomy
   • Infliximab
   • Cyclosporine
9. What newer small molecule is approved for moderate-severe UC? (Tofacitinib - JAK inhibitor, 10 mg twice daily; Ozanimod - S1P modulator)
10. Can corticosteroids be used as maintenance therapy in UC? (NO - only for induction)

7. Surgical Management

1. In which patients with UC is surgery curative? (ALL UC patients - colectomy is curative, unlike Crohn's)
2. What are the indications for emergency colectomy in UC?
   • Toxic megacolon
   • Severe fulminant attack not responding to medical therapy
   • Perforation, massive hemorrhage
3. What is the standard surgical operation for UC? (Total proctocolectomy with Brooke ileostomy)
4. What is the sphincter-saving alternative to ileostomy? (Ileal pouch-anal anastomosis / J-pouch)
5. What is pouchitis? How is it treated? (Inflammation of the ileal pouch; treated with metronidazole 500 mg TID or ciprofloxacin 500 mg BID for 2 weeks)
6. What are the colectomy rates in UC at 1, 5, and 10 years with modern therapy? (~3%, 7%, 10%)

8. Complications

1. What is toxic megacolon? What diameter of colon defines it radiologically? (Transverse colon >6 cm with systemic toxicity)
2. What is the cancer risk in UC? When should surveillance colonoscopy begin? (Start surveillance 8-10 years after diagnosis; every 1-2 years for extensive colitis)
3. What dysplastic change in colonoscopy surveillance of UC warrants colectomy? (High-grade dysplasia, or confirmed low-grade dysplasia)
4. Name at least 3 other serious complications of UC. (Massive hemorrhage, perforation, stricture, PSC, dysplasia/carcinoma)

9. Comparison with Crohn's Disease (High-Yield Viva Topic)

1. What is indeterminate colitis?

10. Quick-Fire Recall Questions

1. Drug of choice for maintenance of remission in mild-moderate UC? (5-ASA / mesalamine)
2. Which biologic agent is used for steroid-refractory UC? (Infliximab, vedolizumab, tofacitinib)
3. What type of anemia is seen in UC and why? (Iron deficiency due to chronic blood loss; also anemia of chronic disease)
4. What imaging is used in suspected toxic megacolon? (Plain abdominal X-ray)
5. True or False: UC can involve the small intestine. (False - limited to colon; backwash ileitis is not true ileal UC)