New presentation

New presentation

ECCO statement 3A (UC 2017)

Symptoms of ulcerative colitis are dependent upon extent and severity of disease and include bloody diarrhoea, rectal bleeding, tenesmus, urgency, and faecal incontinence. Nocturnal defaecation and fatigue are often reported. Increasing bowel frequency, abdominal pain, anorexia, and fever suggest severe colitis [EL5]

Further information

  • Rectal bleeding

  • Increase in stool frequency, sometimes with nocturnal actions

  • Looser stool consistency

  • Urgency and tenesmus

  • Rectal mucus

Symptoms suggestive of IBD

ECCO statement 3C (UC 2017)

A full medical history should include detailed questioning about the onset of symptoms, rectal bleeding, stool consistency and frequency, urgency, tenesmus, abdominal pain, incontinence, nocturnal diarrhoea, and extra-intestinal manifestations. Recent travel, possible contact with enteric infectious illnesses, medication [including antibiotics and non-steroidal anti-inflammatory drugs], smoking habit, sexual behaviour, family history of inflammatory bowel disease or colorectal cancer, and previous appendectomy should be recorded [EL5]

ECCO statement 3D (UC 2017)

Physical examination should include pulse, blood pressure, temperature, weight and height, and abdominal examination for distension and tenderness. Perianal inspection and digital rectal examination may be performed if appropriate. Physical examination may be unremarkable in patients with mild or moderate disease [EL5]

Further information

  • Medical history and examination

  • Exclude infection (stool culture) if symptoms <1 week

  • Confirm presence of inflammation (serum CRP, faecal calprotectin)

  • Consider need to exclude malignancy, especially in elderly

Primary care review

ECCO statement 2A (UC 2017)

Disease extent influences treatment modality, whether oral and/or topical therapy [EL1], and determines onset and frequency of surveillance [EL2]. It is defined by the maximal macroscopic extent at colonoscopy, classified as proctitis, left-sided colitis, and extensive colitis

ECCO statement 3C (UC 2017)

A full medical history should include detailed questioning about the onset of symptoms, rectal bleeding, stool consistency and frequency, urgency, tenesmus, abdominal pain, incontinence, nocturnal diarrhoea, and extra-intestinal manifestations. Recent travel, possible contact with enteric infectious illnesses, medication [including antibiotics and non-steroidal anti-inflammatory drugs], smoking habit, sexual behaviour, family history of inflammatory bowel disease or colorectal cancer, and previous appendectomy should be recorded [EL5]

ECCO statement 3D (UC 2017)

Physical examination should include pulse, blood pressure, temperature, weight and height, and abdominal examination for distension and tenderness. Perianal inspection and digital rectal examination may be performed if appropriate. Physical examination may be unremarkable in patients with mild or moderate disease [EL5]

ECCO statement 3F (UC 2017)

Initial investigations should include full blood count, electrolytes, liver and renal function, iron studies, vitamin D level, C-reactive protein, and faecal calprotectin [EL5]. The immunisation status should be assessed [EL5]. Infectious diarrhoea including C. difficile should be excluded [EL2]. Endoscopy and histology should be performed

Further information

  • Medical history and examination

  • Organise initial investigations

  • Organise lower GI endoscopy to confirm diagnosis and disease extent (supported by multiple ECCO statements)

  • Organise gastroscopy if foregut symptoms or presentation < 20 years old

IBD specialist

Assess severity

  • Small bowel investigation indicated if caecal patch; macroscopic and histologic rectal sparring; discontinuous colonic inflammation; backwash ileitis; IBDU; or symptoms suggestive of Crohn’s disease
  • MR, US, or WCE +/- prior patency capsule can be used
Small bowel evaluation

ECCO statement 3E (UC 2017)

A ‘gold standard’ for diagnosis of ulcerative colitis does not exist. It is established by clinical, laboratory, imaging, and endoscopic parameters, including histopathology. An infective cause should be excluded. Repeat endoscopy with histopathological review after an interval may be necessary if diagnostic doubt remains [EL5]

ECCO statement 3J (UC 2017)

The most common endoscopic feature of ulcerative colitis is continuous, confluent colonic involvement with clear demarcation of inflammation and rectal involvement [EL2]. Endoscopically severe ulcerative colitis is defined by mucosal friability, spontaneous bleeding and ulcerations [EL2]

Further information

  • If possibly infectious colitis, repeat investigations after 6-8 weeks to prove disease resolution and exclude IBD

Intestinal inflammation confirmed

  • Treat IBD unclassified (IBDU) as UC (proctitis, left-sided, extensive) unless Crohn’s disease diagnosed
  • Small bowel investigation (e.g. MR, US, or WCE +/- patency capsule) used to exclude Crohn’s disease
IBDU

Ulcerative Colitis

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