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home - IBD - IBD Diagnosis - UC Diagnosis Written by Dr Sebastian Zeki
Knowledge

Knows the differential diagnosis of IBD including bacterial and
amoebic infection, CMV, IBS, drug induced injury (NSAIDs)
microscopic colitis and vasculitis.

Skills
Uses appropriate investigations including blood tests, stool cultures
and intestinal imaging modalities.

Behaviours
Exhibits sympathy to patient, orders appropriate tests in a timely
manner, and involves members of the multidisciplinary team including
IBD nurse and surgeon as appropriate.

Also...
Knowledge


Knows the major differential diagnoses of IBD including infection –
viral bacterial and amoebic vasculitis ischaemia Behcet’s disease
irritable bowel syndrome etc

Knows the appropriate investigations to distinguish the above and
their limitations

Knows the differential when patient with know IBD presents with
symptoms including – active IBD bacterial overgrowth bile salt
malabsorption obstruction

Skills
Able to identify appropriate investigations to make a positive
diagnosis of IBD or to exclude it

Able to interpret the results of the above investigations
Behaviours
Outline to patients the possible causes of their symptoms
Explains and initiates the appropriate sequence of investigations
Can explain to patients the outcome of the investigations and their
implications

Also...

Knowledge
Assessment
Methods GMP
Understands the appropriate investigations for assessing disease
activity and extent including:
• inflammatory markers in blood (ESR, CRP, highly sensitive
CRP) and stool (faecal calprotectin, lactoferrin etc)
and imaging techniques, including
• upper and lower GI endoscopy, CT and MRI scanning,
capsule endoscopy, enteroscopy and barium imaging
SCE, mini-CEX, CbD 1
Understands the circumstances in which disease activity and extent
should be reassessed, and when complications should be suspected
(e.g. perforation, abscess formation, fistulisation)
SCE, CbD 1 Gastroenterology 2009 Page 106 of 155
Skills
Able to make a clinical assessment of a patient and determine the
requirement for further assessment using inflammatory markers and
imaging
SCE, mini-CEX, CbD 1
Can suspect the presence of complications appropriately and take
appropriate action in terms of investigation and management
SCE, mini-CEX, CbD 1,2
Behaviours
Explains the extent and activity of disease to patients, and to explain
their implications
mini-CEX, MSF 1,2,3,4,
Can liaise with IBD nurses, radiologists and other healthcare
professionals to ensure timely investigation and appropriate
management of IBD and its complications


UC Diagnosis

Investigations for acute severe colitis on admission Patients need a plain AXR. The proximal extent of disease broadly correlates with the distal distribution of faecal residue.The presence of mucosal islands (small, circular opacities representing residual mucosa isolated by surrounding ulceration), or more than two gas-filled loops of small bowel on the radiograph are associated with a poor response to treatment.Flexi sig is warranted if the patient is not responding to steroids in established UC.Phosphate preparation before flexible sigmoidoscopy is considered safe, but is probably best avoided in patients with a dilated colon. When there is macro-scopic and histological rectal sparing, or the presence of a caecal patch in newly diagnosed colitis evaluation of the small bowel is indicated Involvement of the appendix only in left sided or extensive colitis is a common feature of UC and requires no further diagnos-tic work up to exclude CDAssociated in 75%UCAssociated with more responsive disease and higher risk of pouchitis Discontinuous Inflammation Backwash ileitis It is observed in up to 20% of patients with pancolitisMay have more refractory UC Endoscopic Anomalies FBC/ CRPor ESR/ UandE’s/LFTs. Stool sample for MC&S and CDT should be done.For UC excluding proctitis, CRP broadly correlates with clinical activity.In patients with severe clinical activity, an elevated CRP is generally associated with an elevated ESR, anaemia and hypoalbuminaemia.Flexi sig should be done for steroid refrac to look for CMV (immunostain) and PMC. Endoscopic criteria for severe colitis include Extensive mucosal abrasionsDeep ulcerationsMucosal detachment on the edge of these ulcerations Well-like ulceration Moderately active colitisCoarse granular appearanceMucosal erosions Mucosal friability (bleeding to light touch)Mild inflammationErythemaVascular congestion of the mucosa Loss of visible vascular pattern Endoscopic Severity Diagnosis of Ulcerative Colitis Investigation and procedures to establish a diagnosis in general FBC, (C-reactive protein, or ESR), U&E’s, LFTs measured, along with stool MC&S and CDT Abdominal ultrasound and scintigraphy in ulcerative colitisDoppler ultrasound of the superior and inferior mesenteric arteries has been used to evaluate disease activity and risk of relapseSensitivity of 80–90% for colonic/ SB inflammationLow specificity for differentiating UC from other causes of colonic inflammationHydrocolonic ultrasound (abdo USSwith retrograde instillation of water in the colon) v. sensitive for identifying active colitis, but cumbersome.Leukocyte scintigraphy is safe, non-invasive and potentially allows assessment of the presence, extent and activity of inflammation, but the method lacks specificityIt is unreliable if patients are taking steroidsVirtual colonography in ulcerative colitisNot useful. Biomarkers(pANCAs)- found in 65% of patients with UC and < 10% of patients with CD Anti-Saccharomyces cerevisiae antibodies (ASCA)Faecal calprotectin is a sensitive biomarker that reflects intestinal inflammation in established IBD. Not specific for UCA number of other antimicrobial antibodies as ASCA, OmpC, I2, cBir anti-flagellin, ALCA, ACCA, are found mainly in patients with Crohn's diseaseProcedures recommended to establish the diagnosis Colonoscopy, preferably with ileoscopy, and segmental biopsies including the rectumCapsule’s role yet to be clarified Written by Dr Sebastian Zeki

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