WBR1116

Author	[[PageAuthor::Mugilan Poongkunran M.B.B.S [1]]]
Exam Type	ExamType::USMLE Step 3
Main Category	MainCategory::Emergency Room
Sub Category	SubCategory::Gastrointestinal
Prompt	[[Prompt::A 40 year old male comes to the emergency department with complaints of fever, generalized abdominal pain and bloody stools. He was diagnosed with ulcerative colitis 2 years back and has been on and off sulfasalazine treatment. His flare up started 2 days ago and quickly progressed to severe abdominal pain and multiple bloody stools. On examination his vitals are pulse: 104/min, BP: 140/80 mmHg and temperature 38 degree Celsius. Abdominal examination reveals hypoactive bowel sounds and generalized distension with rebound tenderness. Abdominal X-ray shows colonic dilatation of > 6cm with some air fluid levels. There is no pnueumoperitoneum. Initial lab evaluation shows Hb: 10 g/dl, WBC: 18,500/mm3, platelets: 330,000/mm3, blood glucose: 100 mg/dl, serum creatinine: 1 mg/dl and potassium: 3 mEq/L. Stool studies are negative for infectious etiology. Patient is started on intravenous fluids, intravenous steroids, and broad spectrum antibiotics. On the 3rd day of hospitalization his symptoms began to improve. Which of the following would the most appropriate next step in the management of this patient?]]
Answer A	AnswerA::Switch to oral glucocorticoids
Answer A Explanation	AnswerAExp::Switch to oral steroid therapy is done gradually in patients with fulminant colitis showing clinical response to IV steroids over a period of 10 days.
Answer B	AnswerB::Continue intravenous glucocorticoids
Answer B Explanation	[[AnswerBExp::Ulcerative colitis patients with fulminant colitis features with or without toxic megacolon should be treated with IV steroids and if clinical response is seen they should be continued on IV steroids till the 10th day followed by gradual switch to oral steroids. If patients do not respond to initial IV steroid therapy, then toxic megacolon patients should be referred to surgery department for colectomy.]]
Answer C	AnswerC::Discontinue steroids and start oral 5-ASA therapy
Answer C Explanation	[[AnswerCExp::Steroids are the mainstay of treatment ulcerative colitis patients with fulminant colitis features with or without toxic megacolon.]]
Answer D	AnswerD::Switch to intravenous infliximab
Answer D Explanation	[[AnswerDExp::IV infliximab can induce remission rapidly and can be used for the maintenance of remission in patients with severe colitis and fulminant colitis without toxic mega colon not responding to initial IV steroids and is not recommended to patients who respond with initial steroid therapy.]]
Answer E	AnswerE::Perform a complete diagnostic colonscopy
Answer E Explanation	[[AnswerEExp::A full colonoscopy is contraindicated in hospitalized patients with severe colitis because of the potential to precipitate toxic megacolon.]]
Right Answer	RightAnswer::B
Explanation	[[Explanation::Ulcerative colitis (Colitis ulcerosa, UC) is a form of inflammatory bowel disease (IBD), specifically limited to the large intestine or colon, characterized by relapsing and remitting episodes of inflammation limited to the mucosal layer of the colon. The main symptom of active disease is usually diarrhea mixed with blood, of gradual onset. The management of ulcerative colitis varies according to the severity of disease presentation. Fulminant colitis refers to a subgroup of severe ulcerative colitis that have more than 10 stools per day, continuous bleeding, abdominal pain, distension, and acute toxic symptoms with a potential risk of progressing to toxic megacolon and bowel perforation. Patients with intestinal dilation (transverse colon diameter ≥5.5 cm) should receive decompression with a nasoenteric tube and immediately treated with intravenous glucocorticoids, prednisolone (30 mg IV every 12 hours) or methylprednisolone (16 to 20 mg IV every eight hours) without any delay and broad spectrum antibiotics. These patients should be followed up closely with vital signs and physical examination every four to six hours and should be evaluated in the next 72 hours for any clinical signs of improvement. If the patient shows clinical improvement, continue IV steroids till the 10th day and gradually switch to oral therapy, followed by gradual tapering of oral dosage over 4-6 weeks with simultaneous monitoring for any relapse. If patients do not respond to initial IV steroid therapy, then they should be referred to surgery department for colectomy. Educational Objective: Intravenous glucocorticoids are the mainstay of treatment ulcerative colitis patients with fulminant colitis features with or without toxic megacolon and should be continued till the 10th day in cases of positive treatment response before switching to oral steroids. References: ]]
Approved	Approved::Yes
Keyword	WBRKeyword::Ulcerative colitis, WBRKeyword::Inflammatory bowel disease
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