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

Fulminant ❑ > 10 loose stools per day ❑ Continuous bleeding ❑ Severe dehydration ❑ Severe abdominal pain ❑ Abdominal distension ❑ High fever (temperature ≥37.5ºC) ❑ HR ≥90 beats/minute ❑ Hemoglobin <10.5 g/dL ❑ Elevated ESR (≥30 mm/hour) ❑ Rapid weight loss

Fulminant Colitis

No fulminant colitis

Distal 5-8 cm of the rectum

Greater than 8 cm of distal rectum

Extensive colitis/ Left sided colitis

Management of fulminant colitis (look below)

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

Combination of oral and topical therapy ❑ Oral sulfasalazine: Titrated up to 4-6 g/day Or ❑ Oral nonsulfonamide 5-ASA: At least 2 g/day, titrating up to 4.8 g/day of the active 5-ASA moiety PLUS ❑ 5-ASA enemas (1-4 g) and 5-ASA suppositories (500 mg): BID Or ❑ Steroid foam (100 mg) and/or suppositories (30 mg): BID

Oral glucocorticoids ❑ Oral prednisolone: 40-60 mg one or in two divided doses PLUS High dose oral 5-aminosalicylic acid ❑ Oral sulfasalazine: 4-6 g/day Or ❑ Oral mesalamine:4.8 g/day Or ❑ Oral balsalazide: 6.75 g/day PLUS Topical therapy ❑ 5-ASA or steroid suppository PLUS ❑ 5-ASA, steroid enema, or foam

Response to Rx in 4-6 wks

Response to Rx in 4-6 wks

Response to Rx in 4-6 wks

Response to Rx in 4 wk

Yes

No

No

Yes

No

Yes

No

Yes

Combination of oral 5-ASA and topical 5-ASA ❑ Oral sulfasalazine: 4-6 g/day in four divided doses Or ❑ Oral mesalamine: 2-4.8 g/day in three divided doses Or ❑ Oral balsalazide: 6.75 g/day in three divided doses Or ❑ Oral olsalazine: 1.5-3 g/day in two divided doses ❑Start at the lower dose and increase to the maximum tolerated dose OR Combination of topical 5-ASA and topical steroids ❑ Same dosage

Combination of oral 5-ASA and topical 5-ASA ❑ Start from a higher dose OR Combination of topical 5-ASA and topical steroids ❑ Same dosage

Oral glucocorticoids ❑ Oral prednisolone: 40-60 mg one or in two divided doses ❑ Try to Taper dose 5-10 mg weekly over 8 wks until it is 20 mg/day

Inpatient management ❑ NPO ❑ Intravenous fluids: Normal saline or ringer lactate Intravenous steroids ❑ IV prednisolone: 30 mg/12 hrs Or ❑ IV methylprednisolone: 16-20 mg/8 hrs Or ❑ IV hydrocortisone: 100 mg/8 hrs Broad-spectrum antibiotics ❑ IV ciprofloxacin PLUS ❑ IV metronidazole: Venous thromboembolism prophylaxis

Response to Rx in 2-4 wks

Response to Rx in 2-4 wks/ Successful dose tapering

Yes

No

No

Yes

Maintenance therapy ❑ ONLY Rx patients with > 1 relapse a year ❑ Mesalamine suppositories: 500 mg BID or OD

Maintenance therapy ❑ Oral sulfasalazine: 2 g/day Or ❑ Eudragit-S-coated mesalamine: 3.2 g/day Or ❑ Extended release mesalamine capsules: 1.5 g/day in four divided doses Or ❑ Oral balsalazide: 3-6 g/day in three divided doses Or ❑ Oral olsalazine: 1 g/day in two divided doses Or ❑ Combination therapy: Oral mesalamine 1.6 g/day and enema 4g biweekly

Steroid therapy ❑ Oral prednisone: 40-60 mg/day Or ❑ IV infliximab: 5 mg/kg at 0, 2, and 6 wks

Maintenance therapy ❑ Rx all patients after the 1st episode ❑ Mesalamine enemas: 2-4 g/day at bedtime

Steroid resistant UC therapy ❑ Azathioprine: 1.5-2.5 mg/kg/day Or ❑ 6-mercaptopurine (6-MP): 1.5 mg/kg/day

❑ After clinical response, taper dose by 5-10 mg/wk over 8 wks until it is 20 mg/day ❑ Then taper dose by 2.5 mg/week and stop

Failure of maintenance therapy ❑ 6-mercaptopurine (6-MP): 1.5 mg/kg Or ❑ Azathioprine:2-2.5 mg/kg Or ❑ IV infliximab: 5 mg/kg at 0, 2, and 6 wks

Maintenance therapy ❑ Oral sulfasalazine: 4-6 g/day in four divided doses PLUS ❑ Mesalamine suppositories: 1 g/day at bedtime Or ❑ Mesalamine enemas: 2-4 g/day at bedtime

Failure of maintenance therapy ❑ 6-mercaptopurine (6-MP): 1.5 mg/kg Or ❑ Azathioprine:2-2.5 mg/kg Or ❑ IV infliximab: 5-10 mg/kg at 0, 2, and 6 wks

Dont's

Dont start patients with a first episode of mild ulcerative proctitis that has responded promptly to treatment on maintenance therapy.

References

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