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Management of Acute Severe Colitis. Dr Jayne Eaden Consultant Gastroenterologist , UHCW. Symptoms. Bloody diarrhoea (urgency & tenesmus) Abdominal pain Weight loss Obstructive symptoms Abdominal mass (esp RIF). Warning Signs. Fever > 37.8 o C Dehydration

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management of acute severe colitis
Management of Acute Severe Colitis

Dr Jayne Eaden

Consultant Gastroenterologist, UHCW

symptoms
Symptoms
  • Bloody diarrhoea (urgency & tenesmus)
  • Abdominal pain
  • Weight loss
  • Obstructive symptoms
  • Abdominal mass (esp RIF)
warning signs
Warning Signs
  • Fever > 37.8 oC
  • Dehydration
    • Tachycardia (P>90), Hypotension
  • Abdominal pain and tenderness (beware toxic dilatation and perforation)
  • Patients can look well if been on steroids - beware
other signs
Other Signs
  • Mouth ulcers
  • Perianal disease
  • Erythema nodosum
  • Pyoderma gangrenosum
  • Eye disease
  • Arthropathy (large joints, asymmetrical and non-deforming)
truelove witts criteria
Truelove & Witts Criteria

Defines severe Ulcerative Colitis

Bowels open > 6 times per 24 hours

Plus any one or more of the systemic manifestations

  • Haemoglobin < 10.5
  • ESR > 30
  • Pulse rate > 90
  • Temperature > 37.5
differential diagnoses
Differential Diagnoses
  • Bacterial infection
    • C. diff, Campylobacter, Salmonella, Shigella, E. coli 0157
  • Viral infection if immuno-compromised (CMV)
  • Amoeba especially if travel history
  • Crohn’s colitis and ischaemia
  • Diverticulitis can occasionally mimic
investigations on admission
Investigations on Admission

Bloods

  • FBC
  • ESR & CRP
  • U&E, creat
  • LFT (albumin)
  • Blood cultures (if temp > 38°)
  • Glucose
  • (Mg+ and Cholesterol)
investigations on admission1
Investigations on Admission
  • Stool Culture and Microscopy
  • C. Diff (3 separate samples)
  • AXR: look for stool-free colon (indicates extent involved); severe disease indicated by mucosal oedema (thickened wall), mucosal islands, dilated small bowel loops, colonic dilatation (diameter > 6cm)
  • Inform the surgeons on call if the colon is dilated
slide12

Colectomy more likely if:

-Mucosal islands present

-Dilated small bowel loops

investigations on admission2
Investigations on Admission
  • Arrange a sigmoidoscopy and rectal biopsy. DO NOT prescribe bowel prep
    • should be done within 24 - 48 hours of admission
  • Avoid colonoscopy and barium enema in patients with acute, severe colitis
daily investigations
Daily Investigations
  • Bloods
    • FBC
    • U&E, creat (particularly watch the potassium)
    • LFT
    • CRP (a vital prognostic guide)
  • AXR for severe extensive colitis (any of fever, tachycardia, tenderness, dilatation on initial films) – in absence of these criteria less frequent AXR is OK
  • Results must be reviewed the same day (esp potassium) particularly if abdominal X-ray is requested.
extra investigations
Extra Investigations
  • In appropriate patients, send Amoebic Fluorescent Antibody test
  • Check CMV titre if patient is not responding after 3 days (EDTA sample)
daily monitoring
Daily Monitoring
  • Temperature and pulse
  • Stool chart
    • Frequency
    • Colour / blood content
    • Estimate of volume (record even if only passed blood or mucus)
  • Abdo examination findings
    • tenderness, bowel sounds
  • Note increasing pulse / temp / abdominal pain or tenderness may indicate deterioration or frank perforation and requires appropriate urgent investigation and d/w SpR / consultant.
management
Management
  • Rehydrate with IV fluids
  • Correct electrolyte imbalance (in particular potassium)
  • Nutrition : Low residue diet (IV fluids if vomiting)
  • Inform colorectal surgeons & IBD nurse
management1
Management
  • Corticosteroids: Hydrocortisone 100mg QDS IV until remission achieved. May use Predsol/Predfoam PR once or twice per day (mainly for distal disease)
  • Antibiotics (if febrile / toxic dilatation)
  • Severely anaemic patients (Hb < 9g / dl) should be considered for transfusion
  • DVT prophylaxis e.g enoxaparin 40mg od
management2
Management
  • Look for and treat proximal constipation
  • If stop 5-ASA, restart on discharge

DO NOT

  • Use opiates / codeine phosphate/ loperamide (may precipitate paralytic ileus, megacolon and proximal constipation)
  • Use anti-cholinergics
travis criteria
Travis Criteria

After three days of intravenous hydrocortisone, the presence of

either

  • Stool frequency > 8 times per 24 hours

or

  • Stool frequency > 3 times + CRP > 45

gives an 85% likelihood of requiring colectomy on the same admission

the management of acute severe uc options for rescue
The Management of Acute Severe UC: options for rescue.......

If no improvement by day 3 make plans for day 5!

    • Surgery

or

    • Cyclosporine

or

    • Infliximab
  • MUST be discussed with a Consultant Gastroenterologist
indications for colectomy
Indications for colectomy
  • Toxic dilatation with failure to improve clinically / radiologically within 24 hrs
  • Perforation
  • Uncontrolled lower GI haemorrhage
  • Failure to respond after 3 days IV steroids
  • Deterioration at any stage
acute severe uc the role of cyclosporine
Acute severe UC:the role of cyclosporine
  • Only use if stool cultures negative
  • Toxic drug – safety is paramount
    • IV hydrocortisone is continued
    • Check Mg+ and ensure cholesterol >3
    • Be aware of side effects (seizures)
    • Care in elderly / hypertensive / impaired renal function
acute severe uc the role of cyclosporine1
Acute severe UC:the role of cyclosporine

What dose?

  • 2mg/kg as IV infusion in 500mls glucose over 2-6 hrs
  • Monitor levels (100-200mcg/l trough)
    • Levels monitored at UHCW Mon-Fri
  • Rapid steroid wean once clinical response
  • If responded switch to oral after 3-5 days:
    • 5mg/kg/day in 2 divided doses
acute severe uc the role of cyclosporine long term outcome
Acute severe UC:the role of cyclosporine – long term outcome
  • Clinical experience from Oxford
    • 76 pts from 1996-2003 followed 2.9 yrs
    • 54 received 4mg/kg, 22 oral 5mg/kg
    • 74% entered clinical remission and left hospital
    • BUT 65% relapse at 1 yr, 90% at 3 yrs
    • 58% of those came to colectomy at 7 yrs
acute severe uc the role of cyclosporine exit strategy
Acute severe UC:the role of cyclosporine – exit strategy
  • Azathioprine naive vs refractory........
  • Ideally check TPMT levels on admission
  • Commence Azathioprine at discharge
  • Wean off Cyclosporine after 6-8 weeks
  • Septrin 960mg alt days – prophylaxis against opportunistic infection
  • Early follow up to check remission and bloods
acute severe uc the role of infliximab safety issues
Acute severe UC:the role of infliximab – safety issues
  • Possible risk of lymphoma & malignancy
    • Increased if pt on other immunosuppressants
  • Infectious complications (VZV, candida)
    • Serious in 3%
  • TB reactivation (PPD & CXR required prior to treatment)
  • Interactions tacrolimus/ live vaccines
acute severe uc the role of infliximab safety issues1
Acute severe UC:the role of infliximab – safety issues
  • Contraindications:
    • Sepsis
    • Significantly raised LFTs (x3),
    • Hypersensitivity to infliximab
    • Active TB
    • Pregnancy } avoid for 6 months after
    • Breast Feeding } stopping treatment
  • Cautions:
    • Previous TB
    • Hepatic Impairment
    • Renal Impairment
    • Heart Failure
    • Mouse allergies
    • > 14 weeks since last infusion
infliximab for chronic active uc can we predict who will respond
Infliximab for chronic active UC:can we predict who will respond?
  • Serum albumin <30g/l: 67% vs 23% colectomy OR 6.86 (1.03-45.6) p=0.05 (Lees et al APT 2007)
  • No effect of smoking status, age, stool frequency or disease extent
management of acute severe uc summary of evidence
Management of acute severe UC:summary of evidence
  • Acute severe UC requires specialist care within an experienced MDT
  • Confirm diagnosis and exclude infection
  • Non responders should be identified early and salvage therapy considered
  • Controlled trials of cyclosporine vs infliximab are awaited
management of acute severe uc a multi disciplinary model
Management of acute severe UC:a multi disciplinary model

Physicians

Surgeons

The

Patient

Combined approach

Nurses

Dieticians

Pharmacists

Radiologists

Pathologists