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

Management of mild to moderate ulcerative colitis

Mild-moderate ulcerative colitis ❑ Outpatient therapy ❑ Oral rehydration therapy ❑ Symptomatic therapy: Anti-motility agents: Loperamide Anticholinergic agents: Propantheline, dicyclomine, or hyoscyamine

Distal colitis

Extensive colitis

Distal 5-8 cm of the rectum (Proctitis)

Greater than 8 cm of distal rectum (Proctosigmoiditis)

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 ❑ Symptoms so troubling, start with oral steroid therapy

Response to Rx in 4-6 wks

Response to Rx in 4-6 wks

Response to Rx in 2-4 wks

Yes

No

No

Yes

No

Yes

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

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

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

Oral glucocorticoids ❑ Oral prednisolone: 40-60 mg one or in two divided doses

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

On remission for 2 years without any relapses

Multiple relapses on maintenance therapy

Response to Rx in 2-4 wks

Multiple relapses on maintenance therapy

On remission for 2 years without any relapses

Response to Rx in 2-4 wks

Discontinue maintenance therapy

Rx with oral 5-ASA for remission and maintenance

Rx with oral 5-ASA for remission and maintenance

Discontinue maintenance therapy

No

Yes

Yes

No

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

Rx as extensive colitis ❑ Oral glucocorticoids Or ❑ IV infliximab

Intravenous steroids ❑ Inpatient therapy Or ❑ IV prednisolone: 30 mg/12 hrs Or ❑ IV methylprednisolone: 16-20 mg/8 hrs Or ❑ IV hydrocortisone: 100 mg/8 hrs

❑ 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

Response to Rx in 7-10 days

No

Yes

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

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

Switch to oral prednisone (40-60 mg) and start tapering its dose

Response to Rx

Relapse on tapering

Yes

No

Yes

No

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

❑ IV infliximab: 5-10 mg/kg at 0, 2, and 6 week and thereafter every 8 weeks Or ❑ SC adalimumab: 160 mg at week 0, 80 mg at week 2, and then 40 mg every 2 weeks

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

Management of severe and fulminant ulcerative colitis

Severe colitis ❑ Outpatient therapy ❑ Oral rehydration therapy/intravenous fluids according to hydration status ❑ Avoid complete colonoscopy ❑ Avoid anticholinergic, antidiarrheal agents, NSAIDs, and opioid drugs

Fulminant colitis ❑ Inpatient therapy ❑ NPO ❑ Intravenous fluids ❑ Avoid complete colonoscopy ❑ Total parental nutrition ❑ Blood transfusions to have hemoglobin ≥10 g/dL ❑ Monitor vitals every four to six hours ❑ Record the stool output ❑ Avoid anticholinergic, antidiarrheal agents, NSAIDs, and opioid drugs

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

No toxic megacolon

Toxic megacolon (Colonic diameter ≥6 cm or cecum >9 cm and systemic toxicity)

Response to Rx in 2-4 weeks

Yes

No

❑ Taper the dose of steroids as mentioned above ❑ Monitor for any relapses and treat accordingly ❑ Start the patient on maintenance therapy as above

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

Inpatient management ❑Nasoenteric tube decompression Or ❑ Intermittent rolling maneuvers every 2 hrs Or ❑ Knee-elbow position 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 3-5 days

Response to Rx in 72 hrs

Yes

No

Yes

No

❑ Continue IV steroids till 10th day ❑ Switch to oral steroids and monitor the response ❑ Taper the dose of steroids as mentioned above ❑ Monitor for any relapses and treat accordingly ❑ Start the patient on maintenance therapy as above

❑ Continue IV steroids till 10th day ❑ Switch to oral steroids and monitor the response ❑ Taper the dose of steroids as mentioned above ❑ Monitor for any relapses and treat accordingly ❑ Start the patient on maintenance therapy as above

Surgical consultation for colectomy

Cyclosporine ❑ IV cyclosporine: 4 mg/kg per 24 hours as continuous infusion

Infliximab ❑ IV infliximab: 5-10 mg/kg

Response to Rx within 48-72 hrs

Response to Rx in 48-72 hrs

Yes

No

Yes

Bridging therapy ❑ Oral cyclosporine: 8 mg/kg/day as microemulsion ❑ Taper off the glucocorticoids over the first 4-6 weeks ❑ Taper off cyclosporine microemulsion over the next 6-8 weeks ❑ Start then 6-mercaptopurine (6-MP) or azathiopriner>

Surgical consultation for colectomy

❑ IV infliximab: 5-10 mg/kg at 2 and 6 wks and every 8 weeks thereafter

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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