Download Fulminant Colitis

M62 Coloproctology course 2004
Fulminant Colitis
New Challenges
Issues
•
•
•
•
Changing patterns of disease
Developments in drug therapy
Timing surgical intervention
Surgical practice
Patterns of Disease
IBD
• Rising incidence of
Crohn’s disease
Copenhagen
– presentation
– investigation
Patterns of Disease
IBD
• Rising incidence of
Crohn’s disease
Copenhagen
– presentation
– investigation
Patterns of Disease
UC
Crohn’s
Patterns of Disease
non-IBD
• Clostridum difficile
• Vascular disease
• Immune-compromised
Pseudomembranous colitis
Cases
Cdiff
Severe
Mort
Hosp
2300
64
60%
Dallal 2002
Hosp
157
51
20%
Morris 2002
35%
Sharma 2003
38%
Koss 2004
Source
NOF
Nr
239
Gastro
17
13
• Rising incidence 30-100%/10yrs
• Recurrent attacks – 20%
• Subtotal colectomy – 100% mortality
– Pre-op D – 46%
Koss 2004
Pseudomembranous colitis
• Immunosupression
– Lung TT
• CT diagnosis
Cardiac Patients
GI
CCompl diff
Centre
Nrs
Texas
11,000 147
Frankf.
1,000
18
IscMort
aemia
17
23
22%
85%
• Major GI complications- high mortality
• Surgical decisions - complex
– Cardiac surgery: scope: stool cultures
Imuno-compromised patients
• Cytomegalovirus infection
– Refractory colitis
– 30% (16/47) infected
– 8/12 responded to treatment
Wada 2003
• Immunosuppressed IBD
– 23/23 colitis
– 0/10 CRC
– 21/23 early a’gen +ve
• Mimics PMC
Rahbar 2003
Olfinlade 2001
Study of CMV/PMC in acute colitis required
Medical Management
developments
• The Oxford criteria
– the five day rule
Truelove @ Jewell 1974
• Azathioprine
– maintenance of remission
• Cyclosporin
– induction of remission
McCormack G 2002
VanAssche G 2003
Medical Management
challenges
• Uncertain end points
• Masked sepsis
• Late relapse
– immunosuppression
Mallant-Hent 2003
Surgical Issue
• UC - fragile colon
• Crohn’s - loss of planes
• Rectal stump(ed)
Surgical Issue
• UC - fragile colon
• Crohn’s - loss of planes
• Rectal stump(ed)
Surgical Developments
• One stage reconstruction
– cyclosporin
• Laparoscopy
Hyde GM 2001
Hurley BW 2002
Marcello PW 2001
- interval procedure
• Reconstruction in Crohn’s disease?
New Challenges?
• Team management
– MDM
– Shared care
– Mixed wards
Truelove @ Jewell 1974
Patterns of Disease
non-IBD
• Broad spectrum antibiotics
– pseudomembranous colitis
• Multisystem disease
– ischaemic colitis
• Immune-compromised
– viral infections
– multifactorial disease
Clostridium Difficile
• 2,000 cases over 10 years
• 64 colectomies
• incidence rising
– 0.6 - 1.2%
• life threatening cases also doubled
– 3%
Dallal RM,Ann Surg.
2002