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Fulminant Colitis

M62 Coloproctology course 2004. Fulminant Colitis. New Challenges. Issues. Changing patterns of disease Developments in drug therapy Timing surgical intervention Surgical practice. Patterns of Disease IBD. Rising incidence of Crohn’s disease Copenhagen presentation investigation.

candice-howell
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Fulminant Colitis

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  1. M62 Coloproctology course 2004 Fulminant Colitis New Challenges

  2. Issues • Changing patterns of disease • Developments in drug therapy • Timing surgical intervention • Surgical practice

  3. Patterns of Disease IBD • Rising incidence of Crohn’s disease Copenhagen • presentation • investigation

  4. Patterns of Disease IBD • Rising incidence of Crohn’s disease Copenhagen • presentation • investigation

  5. Patterns of Disease UC Crohn’s

  6. Patterns of Disease non-IBD • Clostridum difficile • Vascular disease • Immune-compromised

  7. Pseudomembranous colitis Dallal 2002 Morris 2002 Sharma 2003 Koss 2004 • Rising incidence 30-100%/10yrs • Recurrent attacks – 20% • Subtotal colectomy – 100% mortality • Pre-op D – 46% Koss 2004

  8. Pseudomembranous colitis • Immunosupression • Lung TT • CT diagnosis

  9. Cardiac Patients • Major GI complications- high mortality • Surgical decisions - complex • Cardiac surgery: scope: stool cultures

  10. Imuno-compromised patients • Cytomegalovirus infection • Refractory colitis • 30% (16/47) infected • 8/12 responded to treatment Wada 2003 • Immunosuppressed IBD • 23/23 colitis • 0/10 CRC • 21/23 early a’gen +ve Rahbar 2003 • Mimics PMCOlfinlade 2001 Study of CMV/PMC in acute colitis required

  11. Medical Managementdevelopments • The Oxford criteria • the five day rule Truelove @ Jewell 1974 • Azathioprine • maintenance of remission • Cyclosporin • induction of remission McCormack G 2002 VanAssche G 2003

  12. Medical Managementchallenges • Uncertain end points • Masked sepsis • Late relapse • immunosuppression Mallant-Hent 2003

  13. Surgical Issue • UC - fragile colon • Crohn’s - loss of planes • Rectal stump(ed)

  14. Surgical Issue • UC - fragile colon • Crohn’s - loss of planes • Rectal stump(ed)

  15. Surgical Developments • One stage reconstruction • cyclosporin Hyde GM 2001 • Laparoscopy Hurley BW 2002 Marcello PW 2001 - interval procedure • Reconstruction in Crohn’s disease?

  16. New Challenges? • Team management Truelove @ Jewell 1974 • MDM • Shared care • Mixed wards

  17. Patterns of Disease non-IBD • Broad spectrum antibiotics • pseudomembranous colitis • Multisystem disease • ischaemic colitis • Immune-compromised • viral infections • multifactorial disease

  18. Clostridium Difficile • 2,000 cases over 10 years • 64 colectomies • incidence rising • 0.6 - 1.2% • life threatening cases also doubled • 3% Dallal RM,Ann Surg. 2002

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