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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 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
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•
•
•
•
•
Mouth ulcers
Perianal disease
Erythema nodosum
Pyoderma gangrenosum
Eye disease
Arthropathy (large joints, asymmetrical
and non-deforming)
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
• 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
Bloods
• FBC
• ESR & CRP
• U&E, creat
• LFT (albumin)
• Blood cultures (if temp > 38°)
• Glucose
• (Mg+ and Cholesterol)
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
Colectomy more likely if:
-Mucosal islands present
-Dilated small bowel loops
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
•
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
• In appropriate patients, send Amoebic
Fluorescent Antibody test
• Check CMV titre if patient is not
responding after 3 days (EDTA
sample)
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
•
Rehydrate with IV fluids
•
Correct electrolyte imbalance (in particular
potassium)
•
Nutrition : Low residue diet (IV fluids if
vomiting)
•
Inform colorectal surgeons & IBD nurse
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
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
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.......
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
• 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
• 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 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
• 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
• Azathioprine naive vs refractory........
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•
•
•
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
• 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 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?
• 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
• 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
Physicians
Surgeons
Theapproach
Combined
Patient
Nurses
Radiologists
Dieticians
Pathologists
Pharmacists