2017 European Ulcerative Colitis Guidelines – Diagnosis – Part One of Two Parts

Highlights of Section 5: Extra-intestinal Manifestations

5.1. Anaemia

Anaemia is common in UC, found in 21% of all patients.280

fig4

ECCO statement 5A [statement 1D in Dignass et al.15]

Diagnostic criteria for iron deficiency depend on the level of inflammation. In patients without clinical, endoscopic, or biochemical evidence of active disease, serum ferritin < 30 μg/l is an appropriate criterion [EL 2]. In the presence of inflammation, a serum ferritin up to 100 µg/l may still be consistent with iron deficiency [EL 4]

ECCO statement 5B [statement 1E in Dignass et al.15]

In the presence of biochemical or clinical evidence of inflammation, the diagnostic criteria for anaemia of chronic disease are serum ferritin > 100 μg/l and transferrin saturation < 20%. If the serum ferritin level is between 30 and 100 μg/l, a combination of true iron deficiency and anaemia of chronic disease is likely [EL2]

ECCO statement 5C [statement 2A in Dignass et al.15]

Iron supplementation is recommended in all ulcerative colitis patients when iron deficiency anaemia is present [EL1]

5.2. Arthropathy

Joint involvement is the second most common EIM in UC, occurring in approximately 20% of all patients.297 Arthritis can be classified as axial and peripheral.298

ECCO statement 5D [statement 2D in Harbord et al.7]

Diagnosis of peripheral arthropathy and/or enthesitis* associated with ulcerative colitis is based on signs of inflammation and exclusion of other specific forms of arthritis [EL3]

*‘Enthesitis’ is the term used to describe inflammation at tendon, ligament or joint capsule insertions. It thus applies to disease associated with the spondyloarthritides (SpA) including ankylosing spondylitis, psoriatic arthritis, reactive arthritis and undifferentiated SpA. The term ‘enthesopathy’, however, has a wider meaning and designates all pathological abnormalities of insertions including inflammatory changes and degenerative problems [from Entheses, enthesitis and enthesopathy from Arthritis Research UK.

ECCO statement 5E [statement 2B in Harbord et al.7]

Diagnosis of axial spondyloarthritis is on the basis of clinical features of inflammatory low back pain associated with magnetic resonance imaging or radiographic features of sacroiliitis [EL2]

Axial arthropathy includes sacroiliitis and spondylitis.299–301 The diagnosis of ankylosing spondylitis [AS] is made according to the modified Rome criteria.302MR imaging [MRI] is the current gold standard, as it can show inflammation before bone lesions occur and become visible using plain radiology.303,304

ECCO statement 5F [statement 6A in Harbord et al.7]

Diagnosis of erythema nodosum is made on clinical grounds. In atypical cases, a skin biopsy might be helpful [EL3]. Treatment is usually based on that of the underlying ulcerative colitis. Systemic steroids are required in severe cases [EL4]. Relapsing and resistant forms can be treated with immunomodulators or anti-TNF [EL4]

ECCO statement 5G [statement 6B in Harbord et al.7]

Pyoderma gangrenosum can be treated with systemic corticosteroids [EL4], infliximab [EL1] or adalimumab [EL3], and topical or oral calcineurin inhibitors [EL4]

5.5. Ocular manifestations

Episcleritis [link is from EyeWiki] generally parallels UC activity. It can be self-limiting and usually responds to topical corticosteroids and NSAIDs prescribed alongside treatment of the underlying UC.342 Simple episcleritis does not require referral to an ophthalmologist and may self-resolve. Uveitis [link is from the National Eye Institute] has potentially more severe consequences [and requires prompt ophthalmologic referral and evaluation].

5.6. Hepatobiliary disease

PSC constitutes the most important hepatobiliary condition among UC patients.343 However, peri-cholangitis, steatosis, chronic hepatitis, cirrhosis, and gallstone formation are also over-represented in these patients. Many of the drugs used to treat UC have the potential to cause hepatotoxicity. PSC is a major risk factor for both cholangiocarcinoma and colon cancer.344 High-quality MR cholangiography [MRC] is recommended as a diagnostic test in patients with suspicion for PSC. If MRC is normal and small duct PSC is suspected, a liver biopsy should be considered [see statements 7A to 7C in Harbord et al.7].

Ursodeoxycholic acid was shown to improve the levels of liver enzymes and to reduce the risk of CRC in PSC, but no therapy has been shown to reduce time to liver transplantation, cholangiocarcinoma, or death.345–347

This entry was posted in Family Medicine, Gastroenterology, Guidelines, Internal Medicine, Pediatrics. Bookmark the permalink.