Ulcerative colitis resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mugilan Poongkunran M.B.B.S [2]

Definition

Ulcerative colitis (UC) is a chronic disease characterized by recurring episodes of diffuse inflammation limited to the mucosal layer of the colon, presenting prominently as bloody diarrhea with rectal urgency and tenesmus. It commonly involves the rectum and may extend proximally in a symmetrical, circumferential, and uninterrupted pattern to involve parts or all of the large intestine.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Crohn’s disease itself may present or complicate as a life-threatening condition and must be treated as such irrespective of the causes.

Management

The algorithm is based on the American Journal of Gastroenterology guidelines for management of Ulcerative colitis (UC) disease in adults.

Characterize the symptoms: ❑ Diarrhea (onset, duration, pattern, frequency, type) ❑ Bowel urgency, tenesmus, and incontinence ❑ Abdominal pain ❑ Rectal bleeding ❑ Constipation ❑ Fever ❑ Fatigue ❑ Nausea ❑ Vomiting ❑ Abdominal distention ❑ Loss of appetite ❑ Loss of weight ❑ Mental status change Extraintestinal symptoms: ❑ Skin lesions ❑ Joint pains ❑ Cough, breathlessness ❑ Eye (burning, itching, or redness) Obtain detailed history: ❑ Recent travel H/O ❑ Recent antibiotic/NSAID/other drug H/O ❑ Abdominal/pelvic radiation H/O ❑ Family H/O ❑ Systemic illness H/O

Assess volume status: ❑ General condition ❑ Thirst ❑ Pulse ❑ Blood pressure ❑ Eyes ❑ Mucosa Examine the patient: ❑ Skin (swelling, pain, erythema or ulceration) ❑ Abdomen (mass, distension or tenderness) ❑ Respiratory system (wheezing or crackles) ❑ Cardiovascular system ❑ Anorectal (bleeding) ❑ Eye (swelling, pain, edema or vision loss) ❑ Musculoskeletal (Axial, large and small joints)

Order tests: ❑ Complete blood count (CBC) ❑ Erythrocyte sedimentation rate (ESR) ❑ C-reactive protein (CRP) ❑ Serum electrolytes ❑ Total serum protein and albumin ❑ Stool analysis (occult blood, WBC's, calprotectin, culture, ova and parasites) ❑ Stool for Clostridium difficile toxin ❑ Urinalysis ❑ BUN ❑ Creatinine ❑ Serum glucose ❑ Liver function tests ❑ STD's: VDRL, PCR (HSV), gonococcal culture

Confirmatory diagnostic tests: ❑ Colonoscopy and biopsy ❑ Proctosigmoidoscopy and biopsy ❑ Ileocolonoscopy ❑ Computed tomography (CT) ❑ Barium enema ❑ Magnetic resonance imaging

Findings suggestive of Crohn's disease: ❑ Symmetric, continuous, and circumferential lesions ❑ Biopsy (Mucosal inflammation, noncaseating granuloma, villous atrophy, crypt abscess) ❑ Rectum involvement (95%) ❑ Backwash ileitis ❑ Negative stool examination for infectious causes

Assessment of severity

Mild ❑ < 4 loose stools per day (+/- blood) ❑ No dehydration ❑ Mild crampy pain ❑ No fever ❑ Normal hemoglobin ❑ Normal ESR

Moderate ❑ > 4 loose stools per day (+/- blood) ❑ Mild dehydration ❑ Abdominal pain that is not severe ❑ Low grade fever ❑ Mild anemia not requiring blood transfusions

Severe ❑ ≥6 loose bloody stools per day ❑ Moderate to severe dehydration ❑ Severe abdominal cramps ❑ High fever (temperature ≥37.5ºC) ❑ HR ≥90 beats/minute ❑ Hemoglobin <10.5 g/dL ❑ Elevated ESR (≥30 mm/hour) ❑ Rapid weight loss

Distal 5-8 cm of the rectum

Greater than 8 cm of distal rectum

Topical (rectal) 5-aminosalicylic acid (5-ASA) ❑ Mesalamine suppositories: 500 mg BID or 1 g OD OR Consider Topical (rectal) steroids ❑ Hydrocortisone suppository: 30 mg BID

Topical (rectal) 5-aminosalicylic acid (5-ASA) ❑ Mesalamine enemas: 1-4 g BID PLUS ❑ Mesalamine suppositories: 500 mg BID or 1 g OD OR Consider Topical (rectal) steroids ❑ Hydrocortisone enema/foam: 100 mg BID PLUS ❑ Hydrocortisone suppository: 30 mg BID

Response in 4-6 wks

Response in 4-6 wks

Yes

No

No

Yes

References

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