Ulcerative Colitis

Cryptitis [Ref. Robbins 7^th/e p 849-850]

• The pathology in ulcerative colitis typically involves distortion of crypt architecture, inflammation of crypts (cryptitis), frank crypt abscess, and hemorrhage or inflammatory cells in the lamina propria.

Pathology of ulcerative colitis.

Macroscopic features

• Ulcerative colitis is a mucosal disease that usually involves the rectum and extends proximally to involve all or part of the colon.
• The lesion is continuous and normal areas between the lesions (skip lesions) do not occur.
• With mild inflammation the mucosa is erythematous and has a fine granular surface that appears like sand paper. In severe cases mucosa is hemorrhagic. ulcerated and edematous.
• In long standing cases. inflammatory polyps (pseudopolyp) may be present as a result of epithelial regeneration.
• With many years of disease the mucosa becomes atrophic and featureless and entire colon becomes narrowed and shortened.

Microscopic features 😕

• The important pathological characteristic is that the process is limited to the mucosa and superficial submucosa with deeper layers unaffected except in fulminant disease.
• Two major features in ulcerative colitis suggests chronicity
• Distortion of the crypt architecture of the colon (cryptitits)

– Crypts may be bifid and reduced in number often with a gap between crypt bases and musculoris mucosae.

• Diffuse predominantly mononuclear infiltrate in lanzina propria is universally present

– Neutrophilic infiltration of epithelial layer produce collection of neutrophils in crypt (crypt abscess).

Pseudopolyps are more commonly found in ulcerative colitis than Crohn’s disease.

These are discrete areas resulting from surviving islands of mucosa or heaped up granulation tissue.

Since in ulcerative colitis there is diffuse mucosal inflammation these pseudopolyps are diffusely distributed.

Ref: Pediatric Inflammatory Bowel Disease  By Petar Mamula page 227.

Colectomy for colitis makes no difference to the course of primary sclerosing cholangitis.

Inpatients with associated ulcerative colitis the course of each disease seems independent of the other.

Ref: Schwartz Principles of Surgery, 8th Edition, Page 1210

Pancreatitis is not an associated extraintestinal manifestation of ulcerative colitis.

Ulcerative Colitis is associated with:

➢   Dermatologic:
⇢  â‡¢  â¬—  Erythema nodosum
⇢  â‡¢  â¬—  Pyoderma gangrenosum

➢   Rheumatologic:
⇢  â‡¢  â¬—  Peripheral arthritis
⇢  â‡¢  â¬—  Ankylosing spondylitis
⇢  â‡¢  â¬—  Sacroiliitis

➢   Ocular:
⇢  â‡¢  â¬—  Conjunctivitis
⇢  â‡¢  â¬—  Anterior uveitis/iritis
⇢  â‡¢  â¬—  Episcleritis

➢   Hepatobiliary:
⇢  â‡¢  â¬—  Hepatic steatosis
⇢  â‡¢  â¬—  Fatty liver
⇢  â‡¢  â¬—  Cholelithiasis
⇢  â‡¢  â¬—  Primary sclerosing cholangitis

➢   Urologic:
⇢  â‡¢  â¬—  Calculi
⇢  â‡¢  â¬—  Ileal bladder fistulas

➢   Metabolic bone disorders

➢   Thromboembolic disorders

Ref: Harrisons Internal Medicine, 18th Edition, Chapter 295, Pages 2487-2489

Definition of ulcerative colitis:
Ulcerative colitis (UC) is a chronic inflammatory condition causing continuous mucosal inflammation of the colon without granulomas on biopsy, affecting the rectum and a variable extent of the colon in continuity, characterised by relapsing and remitting course.

IBD unclassified (IBDU): cases where a definitive distinction between UC, Crohn’s disease, or other cause of colitis cannot be made after the history, endoscopic appearances, histopathology of multiple mucosal biopsies and appropriate radiology have been taken into account.

Indeterminate colitis is a term reserved for pathologists to describe a colectomy specimen which has overlapping features of ulcerative colitis and Crohn’s disease.

Ref: Journal of Crohn’s and Colitis (2012) 6, 965–990.

Distribution of ulcerative colitis:

1. Proctitis – involvement limited to the rectum
2. Distal colitis – Left-sided involvement limited to the colon distal to the splenic flexure
3. Pancolitis -Extensive involvement extends proximal to the splenic flexure, including pancolitis

This classification known as the Montréal classification

Ref: Journal of Crohn’s and Colitis (2012) 6, 965–990.

Parameters of truelove witts criteria :

1. Bloody stools/day
2. Pulse
3. Temperature
4. Haemoglobin
5. ESR
6. CRP

Features  of Severe ulcerative colitis as  per truelove witts criteria:

• Bloody stools/day  >6 and
• Pulse  >90/mt
• Temperature > 37.8 C
• Haemoglobin < 10.5 g/dl
• ESR >30 mm/Hr
• CRP > 30

NB :The simplest clinical measure to distinguish moderate from mildly active colitis is
the presence of mucosal friability

Ref: Journal of Crohn’s and Colitis (2012) 6, 965–990.

In clinical practice, ‘remission’ mean a stool frequency ≤3/day with no bleeding and
no urgency. Sigmoidoscopy to confirm mucosal healing is generally unnecessary.

Ref: Journal of Crohn’s and Colitis (2012) 6, 965–990

Patients with ulcerative colitis who have active disease despite prednisolone up to 0.75 mg/kg/day over a period of 4 weeks is called steroid refractory.

Also know:

Steroid-dependent colitis

• Unable to reduce steroids below the equivalent of prednisolone 10 mg/day within 3 months of starting steroids, without recurrent active disease, 
  or
• Those who have a relapse within 3 months of stopping steroids.

Ref: Journal of Crohn’s and Colitis (2012) 6, 965–990

Baron Endoscopic scores for ulcerative colitis

• Score 0: Normal: matt mucosa, ramifying vascular pattern clearly visible, no spontaneous bleeding, no bleeding to light touch
• Score 1: Abnormal, but non-haemorrhagic: appearances between 0 and 2
• Score 2: Moderately hemorrhagic: bleeding to light touch, but no spontaneous bleeding seen ahead of the instrument on initial inspection
• Score 3: Severely haemorrhagic: spontaneous bleeding seen ahead of instrument at initial inspection and bleeds to light touch

linical features of ulcerative colitis :

• Usually present with rectal bleeding, urgency, tenesmus,and occasionally severe constipation.

Ans. is ‘a’ i.e., Diffuse Distribution of polyps

Pseudopolyps (inflammatory polyps) can be seen in both crohn’s disease and ulcerative colitis

• In ulcerative colitis the distribution of these pseudopolyps can be diffuse but in crohn’s disease the distribution can not be diffuse because a classic feature of crohn’s disease is the sharp demarcation of diseased bowel segments from the adjacent uninvolved bowel. When multiple bowel segments are involved the intervening bowel is essentially normal (skip lesions).

o Mucosal edema –

• The hallmark of both ulcerative colitis and crohn’s disease is mucosal inflammation and chronic mucosal damage. So mucosal edema is a feature of both of these diseases.

      The important point is that while in Ulcerative colitis these processes are limited to mucosa or submucosal, in crohn’s disease these processes extend beyond the mucosa and submucosa and involves the entire wall. o Crypt abscesses –

• Crypt abscesses are produced due to infiltration of the neutrophil into crypt lumen.

        These crypt abscesses are not specific for ulcerative colitis and may be observed in crohn’s disease or any active inflammatory colitis.

• Lymphoid aggregates in mucosa –

        The characteristic mucosal feature of idiopathic inflammatory bowel disease on histology includes —

(i)       Distortion of crypt architecture

(ii)     Destruction and loss of crypt

(iii)    Marked increase in lymphocytes and plasma cells in lamina propria.

(iv) These features are specific to inflammatory bowel disease and helps to differentiate idiopathic inflammatory bowel disease from acute infectious colitis and other chronic colitis.

Ans. is ‘a’ i.e., Cryptitis

The Pathology in ulcerative colitis typically involves distortion of crypt architechure, inflmmation of Crypts (Cryptitis), frank crypt abscess, and hemorrhage or inflammatory Cell in the lamina propria.

Ans. is ‘d’ i.e., Noncaseating granuloma

o Noncaseating granuloma is seen in Crohn disease.

Ans. is ‘b’ i.e., Involves rectum and then whole colon backwards

o Ulcerative colitis involves the rectum and extends proximally in a retrograde fashion to involve the entire colon (pancolitis) in more severe cases.

Ans. ‘a’ i.e., Chronic granulomatous disease; ‘c’ i.e., Predisposes to granulolatous disease

Ans. is ‘b’ i.e., Skip lesion

Ans. is ‘a’ i.e., Ulcerative colitis

o Its seem to be associated with ulcerative colitis and occasionally Crohn’s disease (Ulcerative colitis seen in approx 2/3″ of patients of PSC).

Ans. is ‘a’ i.e., Ulcerative colitis

Ans. is ‘b’ i.e., Ulcerative colitis

Ulcerative colitis

Ulcerative colitis is an inflammatory bowel disease characterized by ‑

1)     Inflammation involving only the mucosa and submucosa

2)       Formation of pseudopolyps

3)       Involvement is in a continuous fashion (absent of skip lesions which are characteristic of CD)

o Ulcerative colitis involves the rectum and extends proximally in a retrograde fashion to involve the entire colon (pancolitis) in more severe cases.

C. i.e. Ulcerative colitis

Pyoderma gangrenosum occurs in both ulcerative colitis & Crohn’s diseaseQ. But – 50% of PG occurs in association with UC. And – 2% of active UC patients have PG and another 4% UC patients have erythema nodosum. The mean duration of chronic ulcerative colitis before the appearance of erythema nodosum & PG is 5 & 10 years respectively.

Answer is ‘d’ i.e. PSC reverts after a total colectomy 

• Schwartz writes “In patients with associated ulcerative colitis, the course of each disease seems independent of
  each other. Colectomy for the colitis makes no difference to the course of primary sclerosing cholangitis.”
• Ulcerative colitis is seen in about 2/3 of patients with sclerosing cholangitis, but the converse is not true. The prevalence of PSC in ulcerative colitis patients in only about 4%.
• Also know

– Smoking is associated with decreased risk of both ulcerative colitis & primary sclerosing cholangitis !

Ans is (b) ie., pseudopolyps of ulcerative colitis has high risk of malignancy 

Pseudopolyps associated with inflammatory bowel disease (and amoebic & ischemic colitis) are not premalignant lesion –

Ans is ‘c’ ie Protocolectomy with ileoanal anastomosis 

Ans. is ‘b’ i.e. Done in cases where medical treatment fails & ‘c’ i.e. Pouch surgery done

Ans. is ‘d’ i.e. Rectum 

Ans. is ‘a’ i.e. stricture 

As the inflammation is purely mucosal in ulcerative colitis, strictures are highly uncommon. Any stricture diagnosed in a patient with ulcerative colitis is presumed to be malignant until proven otherwise.

Answer ‘c’ i.e. Mucosa

Ulcerative colitis involves mucosa and superficial submucosa with deeper layers unaffected except in fulminant disease.

Answer ‘a’ i.e. Ulcerative colitis

Answer ‘a’ i.e. Onset in childhood ; ‘b’ i.e. Extensive involvement of colon

• The risk of colon cancer is directly related to the extent and duration of disease, so disease starting in childhood is more likely to undergo malignant change. In ulcerative pancolitis, the risk of carcinoma is approx 2% after 10 years, 8% after 20 yrs and 18% after 30 yrs.. Note that patients with Crohn’s pancolitis have similar risk.
• Pseudopolyps are not premalignant lesions (in contrast to adenomatous polyps which are premalignant lesion)
• Also know
• Differences between colitis associated colon cancer (CACs) and sporadic colon cancer (SCC) Sproadic cancers usually arise from an adenomatous polyp; colitis asso. cancers typically arise from either flat dysplasia or a displasia-associated lesion or mass. multiple synchronous colon cancers occur in 3 to 5% of SCC but in 12% of CAC. the mean age of individual with SCC is in the sixties; the mean age in CAC is in the thirties. SCC exhibits a left-side predominance; whereas CAC is distributed more uniformly throughout the colon. mucinous and anaplastic cancers are more common in CAC than SCC.

Answer ‘b’ i.e. Left sided is more common

• Colitis associated colon cancers are distributed uniformly throughout the colon as against sporadic colon cancers which show a left predominance.
• Also know

“Left sided colitis carries somewhat less risk.” – Schwartz 8/e, p 1085

Answer ‘b’ i.e. Dysplastic sites

In ulcerative colitis, carcinoma arises from dysplastic sites either flat dysplasia or dysplasia associated lesion or mass.

Ans. is ‘a’ i.e., Ulcerative collitis 

• “Poyderma gangrenosum is seen in 1 to 12% of UC patients and less commonly in Crohn’s colitis.” – Harrison
• Pyoderma gangrenosum is a rare but serious ulcerative disorder, often due to serious underlying systemic disease. The important causes include :

–  Ulcerative colitis

– Crohn’s disease

Rheumatoid Arthritis

Myeloma

• Other dermatological manifestation associated with Inflammatory bowel disease :

a)       Erythema nodosum – occurs in both CD (15%) and UC (10%)

b)       Poyderma gangrenosum – 1 to 12% of UC patients and less commonly in Crohn’s colitis.

c)       Poyderma vegetans

d)       Sweet’s syndrome

e)      Neutrophilic dermatosis

f)      Metastatic Crohn’s disease

g)     Psoriasis

h)     Perianal skin tages – found in 70 to 80% of patients with CD especially those with colon involvement

i)     Oral mucosa lesions (apthous stomatitis and cobblestone lesion of the buccal mucosa) are seen often in CD and rarely in UC.

Answer is ‘b’ i.e. Circinate balanitis

• Cricinate balanitis is characterised by

– serpiginous, annular lesions with slightly raised borders on the glans penis of an uncircumcised man.

– in circumcised men papulosquamous plaques and papules occur on the penis.

Extraintestinal manifestation of IBD

A) Dermatologic – explained in previous question

B) Rheumatologic

i)    Peripheral arthritis – more common in CD

ii)    Ankylosing spondylitis – more common in CD

iii)   Sacroilitis – symmetrical

iv)   Hypertrophic osteoarthropathy

v)    Pelvic/femoral osteomyelitis

vi)   Relapsing polychondritis

C) Ocular

i)   Conjunctivitis

ii)   Anterior uveitis/iritis

iii)   Episcleritis

D) Hepatobiliary

i)   Hepatic steatosis (fatty liver)

ii)   Cholelithiasis – more common in CD than UC and occurs in 10 to 35% of patients with ileitis or ileal resection.        

– Gall stone formation occurs because of malabsorption of bile acids.

– ill Primary sclerosing cholangitis – 1 to 5% of patients with IBD have PSC, but 50 to 75% of patients with PSC have IBD.

E) Urologic

i)   Calculi – more common in Crohn’s disease. Calcium oxalate stones are seen due to hyperoxaluria which occurs because of increased absorption of dietary oxalates in colon. In patients with ileal dysfunction, fatty acids are unabsorbed and they chelate calcium leaving oxalate unbound.

ii)   Ureteral obstruction

iii)  Fistulas

F) Others

i)    Thromboembolic disease

ii)   A spectrum of vasculitidies

iii)   Osteoporosis & osteomalacia

iv)- Cardiopulmonary manifestation – endocarditis, myocarditis, pleuropericarditis, ILD

v) Amyloidosis

Ans. is ‘a’ i.e., Primary sclerosing cholangitis 

Primary sclerosing cholangitis is the most serious extraintestinal manifestation of ulcerative colitis and it does not resolve with colectomy.

Also know these important implications of sclerosing cholangitis on ulcerative colitis

• The activity of the diseased mucosa is more severe in patients with combined ulcerative colitis and primary sclerosing cholangitis.
• The risk of colonic cancer is five times greater when compared with ulcerative colitis alone.
• Cancer occurs more on the right side of the colon in patients with primary sclerosing cholangitis and ulcerative colitis.

Ans. is ‘b’ i.e., Ulcerative Colitis 

• Toxic megacolon is defined as a transverse colon with a diameter of more than 5.0 to 6.0 cm with loss of haustration. Although usually associated with ulcerative colitis, toxic megacolon can also be seen in Crohn’s disease.
• Most dangerous complication of toxic megacolon is —> Perforation.
• Precipitating factors for toxic megacolon

1)       Opioid use                           3) Hypokalemia

2)       Anticholinergic use                4) Barium enemas

• T/T of Toxic megacolon –> About 50% of acute dilatations will resolve with medical therapy alone, but urgent colectomy is required for those that do not improve.
• Note: Toxic dilatation can also be rarely seen in

– Crohn’s disease

– Amoebic colitis

– Salmonellosis

Ans is ‘a’ i.e. Pouchitis

“Pouchitis occurs in nearly 50% of patients, and small bowel obstruction is not uncommon.”- Schwartz 9/e

Maingot’s 11/e lists results of a meta-analysis of over 8,300 patients from 18 major studies showing the major complications and outcomes after ileal pouch–anal anastomosis. According to this meta analysis:

Most common complication is—- Pouchitis

Next most common is————— Small bowel obstruction

In Beal Pouch Anal Anastomosis (Restorative Proctocolectomy) the entire colon and rectum are resected, but the anal sphincter muscles and a variable portion of the distal anal canal are preserved. Bowel continuity is restored by anastomosis of an ileal reservoir to the anal canal.

The neorectum is made by anastomosis of the terminal ileum aligned in a “J,” “S,” or “W” configuration. Most common configuration used is the “J” configuration as it is the simplest to construct and functional outcomes are similar in all. (Ref: Schwartz 9/e p1027)

Indications are conditions where colectomy is to be done such as Ulcerative colitis, FAP, Gardner’s syndrome, hereditary nonpolyposis colon cancer.

Complications:

Short-term complications or those that occur within 30 days of surgery include pelvic sepsis and abscesses primarily due to anastomotic or pouch leakage.

Long-term complications include increased bowel movements (average 6 per day), small bowel obstruction, anastomotic strictures, fistulas, sexual dysfunction, pouchitis, and adhesions.

Ans. is ‘c’ i.e., Ulcerative colitis 

Ans. is ‘d’ i.e. Salazopyrin 

Ans. is ‘d’ i.e., Rectum 

Ans. is ‘d’ i.e., Total colectomy and ileostomy 

Ans. is ‘a’ i.e., Peptic ulceration 

Ans. is ‘b’ i.e., Sulfasalazine 

Ans. is ‘c’ i.e., Rectum is always involved 

Ans. is ‘a’ i.e., Ulcerative colitis 

Ans. is ‘b’ i.e., Prednisolone 

Ans. is ‘d’ i.e., Form pseudopolyps 

Answer is A (Ulcerative Colitis)

Presence of mucus and blood in stool along with positive ANCA antibodies suggests a diagnosis of ulcerative colitis

Different Clinical, Endoscopic and Radiographic Features

Answer is B > A (Ulcerative colitis > Crohn’s disease):

Chronic diarrhea, crypt abscess and crypt ulcers may be seen in both forms of inflammatory bowel disease i.e, Ulcerative colitis and Crohn’s disease. However cryptitis and crypt abscesses represent the charachteristic microscopic features in Ulcerative Colitis. Ulcerative colitis is therefore the single best answer of exclusion.

According to Harrison

The characteristic microscopic findings in Ulcerative colitis are crypt distortion,cryptitis and crypt abscesses disease are non-casseating granulomas in all layers of Note

The characteristic microscopic findings in Crohn’s the bowel wall from mucosa to serosa However

Crypt Abscesses are not specific for Ulcerative colitis Aphthoid ulcers and focal crypt abscesses are also seen and may be seen in CD or any other active inflammatory (early lesions) in Crohn’s disease (Harrisons 16th/1779) colitis.

Pathological examination of the bowel wall is Crohn’s disease is more likely to reveal Non casseating granulomas in association with these crypt abscesses while in the case of Ulcerative colitis, crypt abscesses and cryptitis may be the only pathological finding. As the pathological examination does not mention the presence of Non casseating granulomas we may presume that these were not found during the pathological examination of specimen. In the absence of non casseating granulomas, the presence of cryptitis and crypt abscesses favours a diagnosis of ulcerative colitis.

DISTINGUISHING FEATURES OF CROHN^‘S DISEASE AND ULCERATIVE COLITIS :

Answer is A (Ulcerative Colitis)

Toxic megacolon is an important complication of ulcerative colitis.

Answer is B (Ulcerative colitis)

Colonic involvement with ulcerative colitis is characterised by extensive, broad based ulceration of the mucosa in the distal colon or throughout its length.

Pseudopolyps are created by bulging upwards of isolated islands of regenerating mucosa.

Answer is B (Ulcerative colitis)

Pseudopolyps are typically seen in Ulcerative colitis.

Answer is D (5-Aminosalicyclic acid)

Read text below ‘The mainstay of therapy for inflammatory bowel disease remains 5 Aminosalicyclic derrivativs. – CMDT

5 Aminosalicvclic acid:

It is used in active treatment of ulcerative colitis and Crohn’s disease and during disease inactivity in order to maintain remission.

Commonly used formulations of 5 ASA are :

Sulfasalazine

Oral mesolamine agents

Azo compounds : Balsalazide, Olsalazine

Answer is D (Methotrexate)

Methotrexate has not been shown to be effective fbr treating active ulcerative colitis or for maintaining remission.

Answer is a (5-Aminosalicylic Acid):

The mainstay of therapy for inflammatory bowel disease remains 5- Aminosalicylic derivatives – CMDT

Answer is D (Pancreatitis)

Answer is A (Ulcerative colitis)

Malignant potential is seen in both ulcerative colitis and Crohn’s disease, but ulcerative colitis is a more important risk factor than Crohn’s and hence the answer of choice here. Diverticular disease and ischaemic colitis do not predispose to cancer.

The risk of cancer in CD is considerably less than in patients with chronic U.C’ – Ruhhnns.

Confusing fact:

• The cancer risk in CD and IX are probably equivalent for similar extent and duration of disease — Harrison 16^th/ 1788
• Patients with Crohn’s pancolitis have similar risk —

Thus while certain texts are now suggesting that the cancer risk for both CD & UC are probably equivalent, these are other texts which identify U.C. as a significantly more important cause. As we have to pick one single best answer, the option of choice remains U.C.

Answer is A (Increased risk associated with smoking)

Smoking is associated with a decreased risk of developing primary sclerosing cholangitis (and not an increased risk) As in ulcerative colitis, smoking is associated with a decreased risk of primary sclerosing cholangitis’ — CMDT

Two important conditions with decreased risk from smoking

• Ulcerative colitis (UC)Q
• Primary sclerosing cholangitis (PSC) Q

Ans. C: Ulcerative Colitis

Sulfasalazine

• It is a sulfa drug, a derivative of mesalazine (also called 5-aminosalicylic acid, or 5-ASA)
• Sulfasalazine is used in the treatment of inflammatory bowel disease, including ulcerative colitis and Crohn’s disease.
• It is also indicated for use in rheumatoid arthritis and used in other types of inflammatory arthritis (e.g. psoriatic arthritis) where it has a beneficial affect.
• It is often well tolerated compared to other DMARDS.
• It is usually not given to children under 2 years of age.
• It yields the metabolite sulfapyridine which gives rise to side-effects such as agranulocytosis and hypospermia.
• The other metabolite of sulfasalazine, 5-aminosalicylic acid (5-ASA) is attributed to the drug’s therapeutic effect.
• Therefore, 5-ASA and other derivatives of 5-ASA, are now usually preferred and given alone (as mesalazine), despite their increased cost, due to their more favourable side-effect profile.
• Sulfasalazine, and its metabolite 5-ASA, are poorly absorbed from the gut.

Ans. A: Retinitis pigmentosa

GIT premalignant conditions

• Of the four major primary small-bowel tumors (adenocarcinomas, lymphomas, carcinoid, and leiomyosarcomas), adenocarcinomas and lymphomas are associated with diseases that seem to increase the risk of developing these malignancies.
• Immunoproliferative small intestinal disease and celiac disease, are thought to predispose patients to the development of primary lymphoma.
• Increased risk is also associated with conditions, such as immunodeficiency syndromes, nodular lymphoid hyperplasia, Crohn’s disease, the gastrointestinal polyposis syndromes, hereditary nonpolyposis colon cancer, neurofibromatosis, long-standing ileostomy, and urinary diversion procedures.
• Patient with long standing ulcerative colitis are at risk of developing colonic epithelial dysplaia and carcinoma.
• Oral cavity premalignant conditions
• Many oral SCCs develop from premalignant conditions of the oral cavity.
• A wide array of conditions have been implicated in the development of oral cancer, including leukoplakia, erythroplakia, palatal lesion of reverse cigar smoking, oral lichen planus, oral submucous fibrosis, discoid lupus erythematosus, and hereditary disorders such as dyskeratosis congenital and epidermolysis bullosa
• Other pre-malignant conditions include actinic keratosis, Barrett’s esophagus and cervical dysplasia.

Ans. Loss of haustrations

Ans. Ulcerative colitis

Ans. Ulcerative colitis

Ans. Ulcerative colitis

Ans. is b’ i.e., Involves only colon

UC is associated with HLA-DR2, polymorphism in IL-10 gene and an abnormal T-cell response particularly of CD4 T-cells (T_H2 cells).

Ans. is ‘b’ i.e., Ulcerative colitis

• Pseudopolyps are typically seen in Ulcerative colitis.
• The involved mucosa in ulcerative colitis shows broad based ulcers are aligned along the long axis of the colon. Isolated

Ans. is ‘a’ i.e., Ulcerative colitis

• Ulcerative colitis always involves the rectum and extends proximally in continuous fashion to involve part or all part of the colon.
• Involvement of terminal ileum in ulcerative colitis is called backwash ileitis

Ans. is ‘d’ i.e., Methotrexate

Methotrexate in crohn’s disease

• Methotrexate has been shown to be effective for inducing remission in patients with steroid dependent and steroid refractory crohn’s disease.

Agents that may be used for treatment of ulcerative colitis

• 5-ASA
• Glucocorticoids
• Azathioprine and 6 mercaptopurine
• Cyclosporine or TNF alpha therapy (Infliximab).
• Tacrolimus is a macrolide antibody that has shown to be effective in adults with steroid dependent or refractory ulcerative colitis.

Drugs used in crohn’s disease

• Cyclosporine or infliximab
• 6-Mercaptopurine or azathioprine
• Glucocorticoid IV
• Glucocorticoid oral
• Glucocorticoid rectal
• 5-ASA rectal or oral