Investigations for ulcerative colitis

1. Stool samples In ulcerative colitis: pus cells, eosinophils, RBC Stool culture to exclude Salmonella Shigella Campylobacter Clostridium difficle Yersinia Clostridium difficle toxin in stool Warm saline stool mount for haematophagus trophozoites Investigations for ulcerative colitis

3. Ulcerative colitis vs Crohn’s Disease Distribution Diffuse, starting Rectal sparing rectum Frequent skip areas Inflammation Diffuse granularity Cobblestoning Ulceration Small ulcers in Linear diffusely inflamed serpigenous mucosa ulcers Strictures Uncommon Common Investigations for ulcerative colitis

4. Histology Epithelial destruction Infiltration with acute and chronic inflammatory cells Crypt abscess and distortion Purulent exudate Goblet cell depletion Investigations for ulcerative colitis

5. Histology of Crohn’s colitis Focal inflammation Submucosal involvement Granulomas Goblet cell preservation Transmural inflammation Fissuring Focal eosinophilic mucosal infiltrate > granulomas Eosinophils autoflouresce when Geimsa stained sections are stimulated with indirect light flourescence Investigations for ulcerative colitis

6. Helpful tests in indeterminate colitis ANSA + ANCA Antral Biopsy - 14% patients changed diagnosis to Crohn’s Barclay Am J Gastroenterol 2003 Optical coherence tomography differentiates transmural inflammation of Crohn’s vs. mucosal inflammation of ulcerative colitis Shen. Am J. Gastroenterol 2003 Investigations for ulcerative colitis

7. Investigations at admission Haemogram, general blood picture Platelet Count Acid – Base balance Electrolytes: Na, K, Ca, Mg, CL pH, HCO3, base excess Serum creatinine, total proteins, albumin CRP Serum iron, TIBC Liver function tests Investigations for ulcerative colitis

8. Indicators of active disease Urinary N- methyl histamine(UMH) – stable metabolite of histamine – disease extent of UC Barclay Am J Gastroenterol, 2002 Severe attack: Hypokalemia Hypoalbuminemia ? Gamma -2- Globulin ? AST , ALT – transiently --- Malnutrition -- Sepsis , fatty Liver Investigations for ulcerative colitis

9. Plain X-Ray abdomen -- Supine, erect, may show small intestinal dilatation, ‘impending megacolon’, mucosal edema, or perforation Radiology

10. Investigations to determine extra-intstinal manifestations X-ray Pelvic Girdle: Sacroilitis: 2-15%; Spine: AS: 1-2% PSC: 3% Persistently ? SAP x 3 mo Investigations for ulcerative colitis

11. Serology in IBD pANCA – perinuclear antineutrophil cytoplasmic antibody: marker for ulcerative colitis ANSA – anti Saccharomyces cervisiae antibody: marker for Crohn’s Investigations for ulcerative colitis

13. Surveillance Colonoscopy : Cancer surveillance every year after 8-10 yrs Dysplasia warrants colectomy low grade dysplasia – high sensitivity high grade dysplasia – high specificity any dysplasia in any biopsy - Proctocolectomy Biopsy stricture , polyps multiple pseudopolyps - colectomy strictures that cannot be biopsied - colectomy Winawer, Cancer 1992, Lashner, Dig Dis Sci 1990 Investigations for ulcerative colitis

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15. Investigations for ulcerative colitis

16. Recommendations Clinical , stool exam , sigmoidoscopy/colonoscopy, histology: good sensitivity Plain X-ray abdomen – influences management in severe acute attack Barium studies – may be omitted Electrolytes, acid base studies, s. albumin, SAP: influence management decision in sick patients Serology: useful in 10-15% cases of IC good specificity in combination ANCA + ANSA: low sensitivity. 50% cases serology –ve may represent a distinct clinico-serologic entity Investigations for ulcerative colitis

17. Mobile population Doctors transferred once in 2-4 years. Soldiers (10% of clientele) In hospital for relapse (past records available). Reviewed every 6 months when in remission. Soldiers’ families (30% of clientele) keep moving every 2-4 years. Retired soldiers and families (70%) get free treatment usually at nearest military hospitals, but can be seen at referral hospitals. Investigations for ulcerative colitis

18. New cases seen: Data recorded 1989-91: 14/year (Calcutta) 28 1991-1998: 21/year (Pune) 97 1998-2001: 17/year (Chandigarh) 46 2001-2003: 42/year (New Delhi) 79 Approximately 1-2% of OPD attendance Total records available : 250 Males: 140 (56%) Investigations for ulcerative colitis

19. Investigations for ulcerative colitis

20. Extraintestinal disease and complications Arthralgias 31 (Sacroileitis 12) Skin: 1 Aphthous ulcers: 9 PSC: 1 Eyes: Uveitis 2 Thromboembolism: 1

21. First Attack First Week (5 cases) CBC, electrolytes, stool microscopy and culture Treated initially as acute infectious colitis Third week: Sigmoidoscopy & Biopsy Therapeutic trial Investigations for ulcerative colitis